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.ait' 


LECTUR 


ON  THE 


TREATflENT  OF 


FIBROID  TUMORS  OF  THE  UTERUS 


Medical,  Electrical  and  Surgical. 


BY 


FRANKLIN  H.  MARTIN,  M.D. 

prokessor  of  gynecology  post-graduate  medical  school  of  chicago; 
siir(;eon  woman's  hospital  of  Chicago;  gynecologist  Chicago 

CHARITY     hospital     AND    THE     POST-GRADUATE      HOSPITAL; 
CHAIRMAN   SECTION   OF  OBSTETRICS    AND   DISEASES   OF 
WOMEN   OF   THE    AMERICAN  MEDICAL   ASSOCIA- 
TION    (1895);      PRESIDENT    CHICA(;<> 
GYNECOLOGICAL  SOCIETY 
(1895);   ETC.,  ETC. 
AUTHOR  OF  ELECTRICITY  IN   OBSTETRICS   AND  GYNECOLOGY. 


THE  F.   A.   DAVIS  COMPANY,   PUBLISHERS. 
PHILADELPHIA.  -         NEW  YORK.  -         CHICAGO. 

1897. 


^- 


COPYRIGHT  ACCORDING  TO  ACT  OF  CONGRESS 
BY  FRANKLIN  H.  MARTIN,  M.D. 


#• 


-  PREFACE. 


It  was  the  lot  of  the  writer  of  these  lectures  to  have  entered 
J  the  practice  of  gynecology  at  the  dawn  of  antiseptic  surgery. 
^  With  the  possibilities  revealed  by  this  great  advance,  for  fifteen 
years,  the  surgeons  of  civilization  have  been  struggling  toward 
perfection.  In  a  little  more  than  a  decade  wonders  have  been 
accomplished  and  surgery  developed  to  a  science.  During  this 
period  of  unprecedented  activity  the  treatment  of  fibroids  of 
the  uterus  has  received  a  large  share  of  attention  and  may  now 
be  said  to  have  reached  as  high  state  of  perfection  as  any  other 
branch  of  surgery.  The  benign  nature  of  these  tumors,  their 
slow  development,  their  small  mortality  without  treatment 
made  patients  reluctant  to  accept  the  radical  operations. 
Hence  minor  medical  and  surgical  means  were  sought  and 
persistently  cultivated  to  the  limits  of  their  possibilities, 
Krgot,  electricity,  the  Battey-Tait  operation  and  ligation  of 
the  broad  ligaments  are  minor  treatments  which  have  relieved 
much  suffering,  cured  not  a  few  patients,  and  saved  many  from 
the  more  dangerous  procedure  of  hysterectomy.  In  the  devel- 
opment of  these  minor  means,  not  only,  but  in  the  cultivation 
and  improvement  of  the  major  surgical  technique  the  writer 
has  devoted  a  greater  portion  of  his  professional  time  for  the 
last  ten  years.  The  object  of  these  lectures  is  to  place  in  per- 
manent shape  the  outcome  of  this  decade  of  work  and  to  place 
in  the  hands  of  his  friends  and  students  a  mirror,  as  it  appears 
to  him,  of  the  present  status  of  the  treatment  of  fibroids  of 

the  uterus. 

FRANKLIN  H,  MARTIN,  M,D. 

September  1,  1896. 


LECTURE  I. 

Anatomy,  Histology,  Varieties,  Etiology,  Degen- 
eration, Spontaneous  Disappearance,  Etc. 


The  designation,  •'  Fibroid  Tumors  of  the  Uterus,  " 
which  is  employed  throughout  this  work,  is  used  for 
convenience,  euphony,  and  because  it  has  become  the 
established  and  accepted  term  in  America,  for  all 
myomatous  or  fibromatous  enlargements  of  the  uterus. 
These  enlargements  are  also  called:  Myoma  or 
Fibromyoma  Uteri;  Fibrous  Tumors;  Tumeur  Fi- 
breuse ;  Myofibroma  Uteri;  and  Hysteroma  and  Mus- 
cular Tumors  of  the  Uterus. 

gross  anatomy. 

Fibroid  tumors  of  the  uterus  vary  in  size  from  a 
scarcely  perceptible  enlargement  of  the  uterus,  to  a 
tumor  which  may  weigh  more  than  one  hundred 
pounds.  No  definite  limit  of  maximum  dimension 
can  be  assigned;  some  grow  rapidly  to  an  enormous 
size,  while  others,  under  apparently  the  same  condi- 
tions, increase  slowly  and  never  attain  such  propor- 
tions as  to  produce  deformity. 

The  gross  appearance  of  fibroids  of  the  uterus 
differs  as  widely  as  does  their  size.  There  is  no 
accounting  for  the  great  variety  of  shapes  assumed 
by  these  benign  growths.  Each  one  is  a  law  unto 
itself.  For  convenience  we  divide  them  according  to 
their  method  of  development,  which  influences  their 
contour,  into: 

1.  Interstitial. 

2.  Intramural. 


3.  Subperitoneal. 

4.  Submucous. 

An  Interstitial  Fibroid  is  one  in  which  the  new 
growth  is  uniformly  distributed  throughout  the  body 
of  the  uterus,  without  any  large,  distinct  nuclei  of 
development.  The  external  appearance  of  such  a 
fibroid  is  that  of  a  symmetrically  enlarged  uterus, 
without  external  nodular  enlargements,  or  without 
irregular  projections  of  a  submucous  nature  into  the 
cavity  of  that  organ.  These  symmetrical  tumors  often 
grow  to  weigh  many  pounds,  and  frequently  enlarge 
the  cavity  of  the  uterus  until  it  will  measure  many 
inches  in  depth,  proportionately  increasing  the  area  of 
the  endometrium.  I  have  examined  such  cases  where 
the  uterine  canal  measured  fourteen  inches  in  depth. 

Intramural  Fibroids  are  those  in  which  the  new 
tissue  is  confined  to  the  walls  proper  of  the  uterus, 
but  in  which  several  distinct  centers  of  development 
are  apparent  to  the  naked  eye.  While  each  center 
may  possess  several  nuclei,  the  manner  of  growth  is 
not  uniform  throughout  the  uterine  walls.  This 
variety  makes  the  uterus  irregular  and  the  direction 
of  the  canal  uncertain.  The  separate  distinct  centers 
of  development,  as  felt  through  the  uterine  tissue, 
are  much  firmer  and  less  elastic  than  the  new  tissue, 
which  makes  the  typical  interstitial  variety.  Its  out 
surface  frequently  exhibits  to  the  naked  eye,  white 
cartilaginous  centers  surrounded  by  loose  connective 
tissue;  these  centers  are  often  easily  enucleated  from 
the  muscular  tissue  of  the  walls  of  the  uterus.  From 
the  standpoint  of  gross  anatomy  this  variety  is  distinct 
and  unique.  The  intramural  fibroid  is  much  less 
liable  to  develop  into  very  large  tumors,  because  of 
their  tendency  to  become  pedunculated. 

A  subperitoneal  Fibroid  is  one  which  grows  from 
one  or  more  centers  of  development,  which  may 
become  pedunculated,  and  projects  from  the  walls  of 
the  uterus  into  the  peritoneal  cavity.  The  gross 
appearance  of  these  projections  when  cut  through  is 
that  of  the  intramural  variety. 


A  Submucous  Fibroid  is  one  which  grows  from 
one  or  more  centers  of  development  and  projects 
from  the  walls  of  the  uterus  into  its  cavity.  This 
variety  resembles  the  intramural  in  its  gross  appear- 
ance. It  may  become  pedunculated  and  then  becomes 
an  uterine  polypus. 

I  make  the  unusual  distinction  between  interstitial 
and  intramural  fibroids,  not  only  on  account  of 
anatomic  reasons,  but  from  a  therapeutic  and  surgical 
standpoint,  since  their  action  under  the  influence  of 
ergot,  electricity  and  the  knife  is  strikingly  different. 

In  the  examination  of  an  unusual  number  of 
fibroids,  I  can  approximate  the  relative  percentage  of 
the  occurrence  of  the  several  varieties  as  follows: 
Interstitial  55  per  cent.,  subperitoneal  20  per  cent., 
intramural  15  per  cent.,  submucous  10  per  cent. 

HISTOLOGIC   CHANGES. 

Fibromata. — Fibroid  tumors  of  the  uterus  are  rarely 
fibromata;  they  are  less  rarely  a  mixture  of  fibromata 
and  myomata;  while  in  a  large  majority  of  cases  they 
are  pure  myomata.  According  to  Bland  Sutton,  ''typ- 
ical fibromata  are  generally  dense  tumors  consisting 
of  wavy  bundles  of  fibrous  tissue.  The  bundles  are 
composed  of  long  slender  fusiform  cells  closely  packed 
together.  The  tissue  of  the  tumors,  often  arranged  in 
whorls,  is  permeated  by  blood  vessels."  This  same 
writer  says:  "The  difficulty  of  distinguishing 
between  a  myoma,  a  slowly-growing  spindle-celled 
sarcoma  and  a  pure  fibroma  is  well  known  to  skilled 
histologists." 

Myomata  are  tumors  composed  of  unstriped  muscle 
fibers.  Myomata  are  composed  of  long  fusiform  cells 
with  a  rod-like  nucleus;  the  size  of  the  cells  vary 
greatly  in  different  tumors.  The  bundles  of  muscle 
fibers  are  often  interwoven  in  such  a  manner  that  the  cut 
surface  presents  a  characteristic  whorled  appearance. 
(Bland  Sutton.)  The  well-developed  tumor  consists 
of  unstriped  muscle  fibers  mixed  with  more  or  less 
fibrous  connective  tissue  and  fusiform  cells.     (Garri- 


8 

gLies.)  According  to  Pozzi,  on  microscopic  section 
fibromata  (fibro-myomata)  present  smooth  muscular 
fibers  and  connective  tissue  in  varying  proportions. 

Blood  Vessels. — The  vascularity  of  fibroid  tumors 
varies  greatly.  Hard  fibroids  composed  of  an  unusual 
amount  of  fibrous  material  constituted  in  the  main  of 
long  fusiform  cells,  closely  packed  together,  contain 
smaller  and  fewer  vessels  than  the  soft  or  myomatous 
tumors,  composed  of  unstriped  muscular  tissue- fibers 
more  loosely  packed.  The  latter  are  frequently  very 
vascular,  the  blood  vessels  being  easily  traced  into 
their  interior.  The  former  are  often  surrounded  with 
a  loose  fibrous  capsule  which  frequently  contains  a 
free  distribution  of  blood  vessels,  from  which  the 
tumor  proper  draws  its  nourishment.  The  moderately 
vascular  are  slow  in  growth  while  the  soft  vascular 
tumors  develop  rapidly.  "  The  vessels  that  traverse 
these  soft  tumors  are  often  of  larger  size,"  says  Sutton, 
"especially  the  veins,  and  furnish  a  loud  systolic  bruit 
on  auscultation." 

'•  Some  of  these  myomata  are  so  richly  furnished 
with  blood  vessels  that  on  transverse  section  they  look 
not  unlike  erectile  tumors.  Indeed  Virchow  speaks 
of  them  as  'cavernous  or  telangiectatic  myomata.'' 
The  vessels  seen  on  the  cut  surface  are  for  the  most 
part  veins.  Many  excellent  examples  of  the  extreme 
vascularity  of  such  tumors  may  be  found,  and  it  may 
easily  be  conceived  that  under  varying  conditions, 
such  tumors  would  alter  in  size,  and  in  some  cases 
this  has  been  so  marked  that  the  tumor  seemed  to  be 
erectile."     (Bland  Sutton.) 

Winkle  says:  "  Ordinarily  these  tumors  are  not 
very  vascular  but  in  exceptional  cases,  not  only  the 
adjacent  tissues,  but  the  tumor  itself  contains  a  great 
numV^er  of  large  vessels." 

Nerves. — According  to  good  authority  nerves  have 
been  traced  into  the  substance  of  fibro-myomata. 
According  to  Winkle,  Astruc  asserted  that  he  found 
them  in  the  parenchyma  of  a  polypus,  and  Bidder,  in 
a  large   fibroid,    once  found   a   nerve   fiber       Hartz 


described  them  and  their  method  of  termination  in 
the  nuclei  of  the  smooth  muscular  fibers.  Dupuy- 
tren  also  traced  nerve  fibers  into  these  growths. 

Lymphatics. — Fibroids  of  the  uterus  contain  lym- 
phatics. 

Conclusions. — In  the  proportion  that  the  histology 
of  a  fibroid  tumor  approaches  in  microscopic  struc- 
ture fibromata^  does  it  increase  in  density,  become  less 
vascular,  has  a  more  definite  capsule,  is  less  intimately 
connected  with  the  muscular  tissue  of  the  uterus,  is  of 
much  slower  growth  and  is  much  more  liable  to  be  of 
the  intramural  variety. 

In  the  proportion  that  the  histology  of  a  fibroid 
tumor  approaches  in  microscopic  structure,  myomata. 
does  it  decrease  in  density,  become  softer  and  more 
vascular,  is  its  capsule  more  indefinite  because  the 
new  growth  is  more  intimately  distributed  with  the 
the  muscular  structure  of  the  uterus,  is  of  more  rapid 
growth  and  is  much  more  liable  to  be  of  the  interstitial 
variety. 

DEGENERATIVE   CHANGES. 

Fihrocysts. — Mucoid  Degeneration. — According  to 
Bland  Sutton  large  uterine  myomata  are  especially 
prone  to  undergo  a  change,  whereby  large  tracts  of 
the  tumor  substance  soften  and  become  transformed 
into  mucin.  When  this  takes  place  extensively 
the  tumor  is  converted  into  a  spurious  cyst.  He 
adds  that  the  degeneration  is  preceded  by  edema 
of  the  connective  tissue  and  that  the  cells  assume  the 
characteristic  spider-like  form  to  which  the  term 
myxoma  is  applied.  Virchow  says  this  myxomatous 
degeneration  is  characterized  by  an  effusion  of  mucous 
fluid  among  the  muscular  bands,  and  that  it  is  dis- 
tinguished from  simple  edema  by  the  presence  of 
mucin  and  the  multiplication  of  the  nuclei  and  small 
cells.  When  the  bands  between  the  small  round  cells 
and  the  edema  disappear,  small  fluid  collections  exist 
which  form  the  spurious  fibrocysts. 

The  true  fibrocysts,  according  to  Pozzi,  have  a  very 


10 

different  origin.  "  These  cysts  are  formed  in  pre- 
existing cavities,  in  dilated  lymj)li  spaces  comparable 
to  the  similar  dilatations  which  the  blood  vessels  pre- 
sent. The  fluid  which  they  contain  is  limpid  and 
coagulates  on  contact  with  the  air.  Leopold  has 
termed  these  tumors  'lymph  angiectatic  myoma.'  It 
must  be  noted  that  this  lymphatic  origin  of  certain 
cystic  tumors  of  the  uterus  had  already  been  clearly 
formulated  by  Koeberle.  This  formation  seems  to 
be  due  to  the  development  of  part  of  the  tumor 
along  the  path  of  the  lymph  vessels  contained  in 
the  broad  ligament.  On  the  internal  surface  of  such 
tumors  we  can  demonstrate  an  epithelial  investment 
which  distinguishes  them  from  simple  cavities  formed 
from  softening  of  the  neoplasm  or  apojolexy  into 
its  substance.  There  are  also  mixed  forms  in  part 
vascular  and  in  part  lymphatic." 

Induration. — Fibroids  contract,  reduce  and  harden 
as  a  rule  following  the  menopause,  while  occasionally 
they  disappear  entirely.  The  same  change  takes  place 
after  confinement,  in  myomata  of  the  fundus  of  the 
uterus  which  complicates  pregnancy.  The  change 
resembles  much  that  occurs  in  a  fibroid  after  the 
removal  of  the  appendages.  The  cause  of  the  change, 
in  each  instance,  is  doubtless  due,  to  a  lessening  of 
the  blood  supply. 

Fatty  Degeneration. — Literature  does  not  record 
many  well  authenticated  cases  of  fatty  degeneration  of 
fibroids.  That  it  does  occasionally  occur,  there  is  lit- 
tle doubt,  although  so  rarely  that  from  a  clinical 
8tandi)oint  it  is  of  little  value. 

Calcareous  Degeneration.— 0\di  uterine  myomata, 
both  large  and  small,  are  liable  to  become  infiltrated 
with  earthy  matter.  The  change  only  occurs  in  slow 
growing  tumors  containing  a  large  proportion  of 
fibrous  tissue.  The  calcareous  material  is  not  deposited 
in  an  irregular  manner  in  the  tissues  of  the  tumor,  but 
corresponds  to  the  disposition  of  the  fibers;  on  exam- 
ining the  sawn  surface  of  a  completely^  calcified 
uterine  myoma  we  find  the  whorled  disposition  of  the 


11 


fibers  so  completely  reproduced  as  to  leave  no  doubt 
as  to  the  nature  of  the  mass.  When  these  calcified 
tumors  are  macerated  and  the  decayed  tissues  washed 
away,  the  earthy  matter  retains  the  shape  of  the  tumor, 
but  its  exterior  presents  an  irregular,  porous,  almost 
worm-eaten  appearance.  The  calcification  is  confined 
to  the  tumor  itself,  and  though  we  may  occasionally 
find  isolated  nodules  of  earthy  matter  dotted  about 
the  capsule,  this  part  of  the  tumor  is  not  converted 
into  a  hard  resisting  shell. 

Suppuration. — Suppurating  fibroids  may  be  fibroid 
enlargements  of  any  variety  which  by  some  accident 
have  become  infected.  Fortunately  it  is  a  condition 
which  occurs  but  rarely.  Occasionally  a  subperitoneal 
fibroid,  which  in  process  of  pedunculation  has  been 
deprived  of  a  portion  of  its  blood  su^Dply,  by  a  grad- 
ual narrowing  of  the  pedicle,  may  become  infected  by 
migration  of  microbes  through  the  walls  of  an  adjacent 
intestine  upon  which  pressure  has  been  long  main- 
tained. An  interstitial  fibroid  may  be  converted,  in 
rare  instances,  into  a  suppurating  mass  through  infec- 
tion, by  direct  continuity,  from  a  suppurating  endo- 
metritis. Submucous  polypi,  of  low  vitality  and  small 
resistance  to  pathogenic  microbes,  quite  often  are 
infected  from  the  endometrium  and  the  vaginal  secre- 
tions, and  suppurate,resulting  in  an  offensive  discharge 
of  pus,  and  occasionally,  hemorrhages — all  of  which 
may  give  rise  to  a  suspicion  of  malignant  disease  of 
the  uterus. 

Carcinomatous  Degeneration. — I  have  had  an 
opportunity  of  examining  and  having  under  observa- 
tion, for  long  periods,  an  unusually  large  number  of 
fibroid  tumors  of  the  uterus,  and  I  have  never  known 
one  to  undergo  carcinomatous  degeneration.  My 
experience  coincides  with  that  of  the  best  authorities 
on  this  subject.  Fibroid  tumors  do  not  predisjDose  to 
carcinomatous  degeneration.  Cancerous  changes  may 
occur,  however,  in  a  fibroid  uterus  as  a  coincidental 
disease,  but  in  no  way  as  a  direct  result  of  the  fibroid. 

Spontaneous  Disappearance. — Almost  every  author- 


12 

ity  who  has  watched  the  course  of  many  fibroid 
tumors  of  the  uterus,  has  witnessed  the  spontaneous 
disappearance  of  one  or  more  of  these  growths,  with- 
out any  apparent  cause.  Gusserow  at  one  time  suc- 
ceeded in  gathering  from  literature  thirty  cases  in 
which  this  undoubtedly  occurred.  Of  these  thirty, 
thirteen  were  associated  with  pregnancy,  while  the 
majority  of  the  remainder  were  connected  with  the 
menopause.  It  is  not  difficult  to  explain  the  disap- 
pearance of  a  fibroid  which  has  been  coincidental  with 
pregnancy;  the  process  of  involution  of  the  uterus 
which  occurs  after  confinement,  is  imparted  to  the 
myoma,  which  so  nearly  resembles  the  uterine  tissue, 
and  the  tumor,  consequently,  is  greatly  diminished, 
or  disappears  altogether.  Then  too,  the  decrease  of 
the  blood  suiDi)ly  to  the  uterus,  as  involution  takes 
place,  deprives  the  tumor  of  its  accustomed  nourish- 
ment, and  thus  causes  its  diminution. 

The  reduction  in  size,  or  disappearance  of  a  fibroid 
at  the  menopause  may  be  accounted  for  on  the  theory 
of  diminished  blood  supply,  and  consequent  starva- 
tion. When  senile  atrophy  begins  in  the  organs  of  the 
pelvis,  and  m^enstruation  ceases,  with  consequent 
decrease  in  the  requirements  of  blood  supply,  the 
uterus  atrophies,  and  necessarily  a  tumor  dependent 
upon  that  organ  for  nourishment,  must  also  suffer 
anenda  and  reduction  in  growth. 

But,  occasionally,  fibroids  of  the  interstitial  variety 
will  suddenly  and  mysteriously  disappear,  without 
any  apparent  cause.  1  know  of  one  which  decreased 
in  size,  fully  two-thirds,  as  the  result  of  a  simple 
exjjloratory  operation. 

These  tumors  may  also  be  spontaneously  expelled 
by: 

1,  Pedunculation — a  gradual  narrowing  and  length- 
ening of  the  pedicle,  until  by  violence  or  suppuration 
the  stem  separates.  This  may  occur  with  either  a 
subj^eritoneal  or  a  submucous  i)olypus. 

2.  Enucleation — This  may  occur  with  a  submucous 
or  an   intramural   of   the   hard   variety    (fibromata) 


13 

which  is  usually  surrounded  with  a  loose  capsule,  and 
which  at  its  nearest  approach  to  the  mucous  mem 
brane  becomes  infected.  The  suppuration  will  grad- 
ually encircle  the  mass,  and  by  means  of  uterine  con- 
traction, the  tumor  will  slowly  be  shelled  from  its  bed 
and  expelled  from  the  uterus. 

3.  Suppuration. — Spontaneous  disappearance  of 
fibroids  occurs  as  the  result  of  suppuration  following 
infection. 

ETIOLOGY. 

Pathologists  have  been  unable  to  satisfactorily  dem- 
onstrate the  causes  for  the  development  of  fibroids  of 
the  uterus. 

Pozzi  says  of  Velpeau's  theory,  attributing  the 
development  of  fibroids  to  the  presence  of  a  blood 
clot  in  the  uterine  tissue:  "The  spontaneous  organi- 
zation of  coagula  after  ligation  of  the  arteries  sug- 
gested the  idea  that  the  same  process  might  result  in 
the  formation  of  these  neoplasms.  But  experimental 
study  has  demonstrated  that  this  organization  of  coag- 
ula is  nothing  but  an  ingrowth  of  the  elements  of  the 
vessel's  wall  and  thus  this  edifice  of  theor}^  founded 
on  lack  of  observation,  collapses  altogether. 

"Klebs  asserts  (Pozzi)  that  these  tumors  have  their 
origin  in  a  proliferation  of  the  connective  tissue  and 
muscular  layers  of  certain  vessels ;  the  different  nod- 
ules thus  formed  become  aggregated  to  make  one 
tumor.  Kleinwachter  describes  the  evolution  of  fibro- 
mata as  due  to  a  round  cell  which  is  found  along  the 
capillaries  and  produces  a  partial  obliteration  of  them; 
these  cells  then  become  fusiform  and  produce  nod- 
ules. In  other  words,  our  knowledge  of  the  subject 
is  still  very  imperfect." 

Winkle,  without  any  clear  demonstration  or  expla- 
nation, attributes  the  dependence  of  these  growths 
to  the  peculiarities  of  the  vessels  of  the  uterus,  in 
that  the  arteries  are  subjected  to  a  very  high  pressure 
before  they  reach  the  uterine  wall,  notwithstanding 
their  convoluted  course 


14 

Senn  believes  in  Cohnheim's  theory  of  tumor  devel- 
opment as  modified  by  himself,  viz.:  That  tumors 
never  develop  from  mature  tissue  but  from  a  matrix 
of  embryonic  tissue.  According  to  Senn  this  matrix 
of  embryonic  tissue  may  be  either  of  pre-  or  post-natal 
origin.  "A  fibroid,"  he  says,  "in  the  majority  of  cases 
springs,  no  doubt,  from  a  matrix  of  mesoblast  in  the 
uterine  tissue,  while  in  exceptional  cases  the  tumor 
may  start  from  a  similar  matrix  in  the  wall  of  blood 
vessels.'* 

AGE    AND    DOMESTIC    CONDITION    AS    PREDISPOSING 

CAUSES. 

Fibroids  seldom  occur  before  puberty.  In  575 
autopsies  upon  females  by  Winkle,  12  per  cent,  had 
these  developments.  Of  135  examined  in  the  dead 
house  by  him,  under  35  years  of  age,  only  5  per  cent, 
had  fibroids. 

Dr.  Emmet,  who  has  made  a  most  careful  study  of 
this  subject,  basing  his  opinion  on  recorded  cases, 
says:  "It  is  impossible  to  determine  with  accuracy 
the  age  at  which  these  growths  are  most  likely  to 
appear,  since  their  development  is,  as  a  rule,  slow  at 
first,  and  they  may  exist  for  an  indefinite  period 
before  their  presence  is  recognized.  The  age  can 
only  be  approximately  inferred  from  the  average  one 
at  which  professional  advice  was  first  sought,  and  this 
would  seldom  be  before  the  tumor  had  reached  a  suffi- 
cient size  to  cause  hemorrhage  or  some  other  disturb- 
ance. We  may  also  gain  some  information  as  to  the 
rapidity  of  growth  from  the  length  of  time  elapsing 
after  the  birth  of  the  last  child,  for  a  fibroid,  it  is  well 
known  is  a  cause  of  sterility.  In  the  table  is  shown 
the  age  at  which  225  women,  who  had  fibroid  growths, 
were  first  examined.  The  earliest  age  was  18,  an 
unmarried  woman;  the  next  a  sterile  woman  at  the 
age  of  22;  1  at  23;  10  between  the  ages  of  24  and  25." 
His  table  then  gives  25  cases  between  the  ages  of  25 
and  30;  50  cases  between  the  ages  of  30  and  35;  48 
cases  between  the  ages  of  35  and  40;  42  cases  between 


15 

the  ages  of  40  and  45;  25  cases  between  the  ages  of 
45  and  50;  8  cases  between  the  ages  of  50  and  55; 
and  5  cases  between  the  ages  55  and  60.  Thus  accord- 
ing to  this  table,  which  corresponds  closely  with  the 
experience  of  other  writers,  the  age  of  greatest  liabil- 
ity to  fibroids  is  shown  to  be  between  30  and  35 
years. 

According  to  Emmet,  based  upon  statistical  tables, 
•'between  the  ages  of  30  and  40  years  the  unmarried 
woman  is  fully  twice  as  subject  to  fibrous  tumors  as 
the  sterile  or  as  the  fruitful;"  he  adds,  "It  seems  as 
if  it  were  the  purpose  of  nature  that  the  uterus  should 
undergo  the  changes  dependent  upon  pregnancy  and 
lactation  about  three  years  throughout  the  childbear- 
ing  period,  and  that  if  the  uterus  is  not  physiolog- 
ically occupied  in  childbearing,  a  fibroid  will  the 
more  rapidly  develop.  .  .  .  This  will  also  be  the 
case  with  the  married  woman  who  has  taken  means  to 
prevent  conception,  as  well  as  with  her  who  has  been 
sterile  from  some  cause  beyond  her  control,  but  to  a 
less  degree  in  the  latter  case.  .  .  .  Finally,  the 
woman  who  may  have  been  fruitful  in  early  life,  but 
remained  sterile  long  afterward  from  some  accidental 
cause,  may  have  a  tumor  developed,  but  is  less  liable 
thereto  from  having  once  borne  a  child." 

Brooks  Wells  says:  "Myomata  of  the  uterus  are 
more  common  in  old  maids  than  in  married  women." 
This  statement  is  often  disputed  by  gynecologists  who 
do  not  frequent  the  dead  house.  Very  many  exam- 
ples of  myomata  appear  postmortem  whose  presence 
was  not  even  suspected  during  life. 

Race. — It  is  an  undeniable  fact  that  the  negro 
women,  with  the  environments  of  this  country,  are 
more  liable  to  have  fibroids  of  the  uterus  than 
white  women.  This  statement  is  doubted  by  Dr. 
Middleton  Mitchel,  of  Charleston,  S.  0.  I  can  not 
but  believe,  however,  that  Mitchel  is  wrong,  espec- 
ially as  far  as  the  negro  women  living  in  the 
northern  and  colder  latitudes  of  the  country  are 
concerned. 


16 


SUMMARY. 

The  cause  of  fibroid  tumors  of  the  uterus  has  never 
been  satisfactorily  demonstrated. 

Fibroids  of  the  uterus  rarely  occur  before  puberty, 
and  seldom  before  the  age  of  25,  while  the  greatest 
number  develop  between  the  ages  of  30  and  40  years. 

The  unmarried  state  predisposes  women  to  the 
development  of  uterine  fibroids.  Married  women 
who  prevent  conception,  while  less  liable  to  develop 
fibroids  than  unmarried  women,  are  still  much  more 
prone  to  them  than  childbearing  women.  Childbear- 
ing  women  are  the  least  predisposed  to  fibroid  of  the 
uterus. 

Xegro  women  are  predisposed  to  uterine  fibroids. 


LECTURE  II. 


Symptoms — Diagnosis. 


A  knowledge  of  the  existence  of  a  fibroid  tumor  of 
the  uterus  may  be  gained  by  the  diagnostician  by 
first  (obtaining  the  symptoms  as  appreciated  by  the 
patient — the  subjective  symptoms;  and  further  by 
acquainting  himself  with  the  actual  physical  changes 
by  direct  personal  examination  of  the  patient — the 
objective  symptoms. 

SUBJECTIVE  SYMPTOMS. 

Pelvic  Symptoms. — Among  the  early  local  symp- 
toms of  fibroid  tumors  of  the  uterus  may  be  enumer- 
ated an  irritable  bladder  amounting  frequently  to 
positive  dysurea;  rectal  pressure;  sensation  of  pelvic 
fullness;  low  backache  or  sacralgia,  and  frequently 
pain  on  cohabitation.  These  symptoms  are  all  ijro- 
duced  by  a  gradually  enlarging  uterus,  and  resemble 
many  of  the  pelvic  disturbances  of  early  pregnancy, 
from  which  they  must  be  differentiated.  As  the 
tumor  enlarges  ihe  sensation  of  fullness  extends  to  the 
lower  abdomen,  the  j^ressure  on  the  nerves  to  the 
lower  extremities  causes  pain  in  the  line  of  the  nerves 
on  the  anterior  or  posterior  aspect  of  the  thigh,  or  on 
both.  Even  edema  of  the  extremities  may  occur 
from  pressure  on  the  veins  extending  to  them,  and 
the  appendages  are  frequently  pressed  upon,  resulting 
in  severe  pain  on  one  or  both  sides,  while  as  the 
tumor  begins  to  fill  the  abdomen  symptoms  of  painful 
pressure  on  many  or  all  the  imp(H'tant  organs  of  the 
pelvis  will  be  experienced. 


18 


Symptoms  due  to  Functional  Disturbances. — The 
most  important  symptom  under  this  head  is  that  due 
to  the  disturbance  of  the  function  of  menstruation. 
In  75  per  cent,  of  all  fibroid  tumors  of  the  uterus  the 
menstrual  flow  is  increased,  on  account,  1,  of  increased 
area  of  the  endometrium  due  to  interstitial  enlarge- 
ment of  the  uterus,  2,  of  increased  vascularity  of  the 
uterus  due  to  the  demands  of  the  hypertrophied  tis- 
sues, and  3,  to  the  venous  blood  congestion  due  to 
pelvic  i^ressure.  In  a  large  majority  of  cases  pain  is 
an  accompanying  symptom.  This  dysmenorrhea  is 
caused,  either  by  the  abnormal  contractile  power  of 
the  changed  uterus,  by  submucous  projections  into 
the  uterine  cavity,  exciting  painful  contractions  of  the 
organ,  or  by  a  frequently  accompanying  endometritis. 
The  development  of  the  tumor  influences  decidedly 
the  change  of  the  menstrual  function.  In  the  early 
stages  of  the  fibroid  the  patient  will  notice  but  a  slight 
lengthening  of  the  menstruation,  but  as  further  devel- 
opment is  made  the  quantity  of  the  flow  will  be  in- 
creased. This  changed  condition,  while  at  first  it  may 
attract  the  attention  very  slightly,  as  it  gradually  in- 
creases, will  at  last  convince  the  patient  that  some- 
thing serious  is  afflicting  her.  The  flow  will  increase 
rapidly,  not  only  in  length  of  period,  and  in  quantity 
at  a  given  time,  but  finally  it  will  frequently  become 
irregular  and  occasionally  almost  continuous.  At  the 
same  time  pain  will  often  gradually  develop,  so  that 
with  the  exhaustion  of  depletion  will  come  the  agony 
of  physical  suft'ering.  These  pains  if  caused  by  en- 
dometritis, will  be  of  a  dull  aching  character,  accom- 
panied occasionally  with  slight  uterine  contractions; 
if  caused  by  the  effort  of  the  uterus  to  expel  submu- 
cous masses  or  polypi,  it  will  be  like  those  accompa- 
nying the  uterine  expulsive  pains  of  a  miscarriage  or 
confinement;  if  caused  ])y  a  pressure  of  the  inordin- 
ately congested  hypertrophied  uterus  upon  the  tubes 
and  ovaries  it  will  be  severe  and  of  an  almost  continu- 
ous character  in  the  ovarian  regions. 

The  function   of  the   bladder  suffers  from  direct 


19 


pressure  of  the  enlarged  uterus,  or  from  a  subperito- 
neal enlargement.  Frequent  urination  will  first  be 
noticeable,  while  the  tumor  is  yet  small,  and  later  pain- 
ful micturition,  with  severe  lasting  x^ain  in  the  bladder, 
as  a  direct  result  of  traumatism  produced  by  the  en- 
croachments of  the  uterus.  Comjilete  stopi)age  of  the 
urine  and  painful  distention  of  the  bladder  may  finally 
occur  from  impaction  of  the  increasing  tumor. 

The  function  of  the  rectum  is  frequently  im^^aired 
by  direct  pressure  of  the  tumor  uj^on  that  organ. 
Obstinate  constipation  will  be  complained  of,  while 
the  interference  of  the  tumor  with  the  circulation  will 
favor  the  development  of  hemorrhoids  and  their  pain- 
ful symptoms.  Temporary  imi3action  of  feces  in  the 
large  and  small  intestines  occur  as  a  direct  result  of 
the  pressure  of  a  large  tumor. 

Deformity  Produced  by  Fibroids. — One  of  the  most 
embarrassing  symjDtoms  to  many  patients,  who  are 
afflicted  with  fibroid  tumors,  and  frequently  the  firsi 
to  attract  their  attention,  is  the  change  in  the  contour 
of  the  abdomen,  which  is  enlarging.  Upon  closer  ob- 
servation and  examination  of  the  lower  abdomen,  they 
discover  the  un wieldly  mass,  the  tumor,  which,  as  it 
gradually  increases  in  size,  produces  a  deformity  that 
no  device  can  conceal,  while  the  patient,  in  order  to 
maintain  an  upright  position,  must  throw  her  shoul- 
ders back  in  a  manner  to  make  the  tumor  appear  most 
embarrassingly  conspicuous. 

General  Co)istifufiona1  Disturbances. — Reflex  ner- 
vous disturbances  are  early  symptoms  in  many  of 
these  cases.  Nausea,  palpitation  of  the  heart,  indi- 
gestion, gaseous  distensions  of  the  bowels,  flashes  of 
heat  due  to  vasomotor  disturbances,  headache,  dizzi- 
ness, occasionally  spasmodic  cough  and  all  the  symj)- 
toms  accomj^anying  nervous  storms,  irritable  temper, 
<lespondency,  and  lack  of  control,  finally  developing 
into  typical  hysteria.  These  symptoms  are  precipi- 
tated ordinarily  by  irritation  caused  by  the  long-con- 
tinued local  disturbances  already  described,  and  by 
loss  of  blood  due  to  excessive  menstruation. 


20 


Anemia  naturally,  in  a  large  number  of  cases,  be- 
comes a  conspicuous  subjective  symptom.  The  patient 
will  complain  of  loss  of  Hesli,  lier  skin  has  become 
pale,  lips  pale  and  blue,  muscles  loose  and  flabby.  She 
tires  easily,  and  all  exercise  induces  shortness  of 
breath  and  heart  palpitations.  Frequently  it  is  nec- 
essary to  remain  in  bed  a  large  part  of  the  time  from 
weakness,  which  is  much  more  pronounced  immedi- 
ately following  the  great  waste  of  the  menstrual 
period. 

OBJECTIVE  SYMPTOMS. 

Diagnosis. — Under  objective  symptoms  methods  of 
diagnosis  will  be  considered.  Objective  symptoms 
are  determined,  and  their  diagnostic  value  recognized, 
by  pelvic  examination,  abdominal  palpation  and  aus- 
cultation, and  general  examination. 

Priric  Ejarni nation. — The  i^atient  should  be  placed 
on  her  back  on  an  oj^erating  chair  or  table,  in  the  re- 
cumbent position,  w4th  limbs  well  flexed  upon  the 
abdomen,  and  feet  supported  by  short  stirrups.  The 
clothing  should  be  loose.  After  the  vagina  has  been 
well  douched  with  an  antiseptic  fluid,  the  examiner 
should  proceed  to  make  a  bimanual  pelvic  examina- 
tion. The  index  finger  of  the  left  hand  is  employed 
to  make  the  preliminary  vaginal  examination,  the 
right  hand  being  left  free  for  external  manipulation. 
The  cervix  is  first  sought  and  its  location  often  gives 
one  important  information.  If  it  is  in  normal  posi- 
tion, well  up  in  the  vagina,  within  an  inch  and  a  half 
of  the  sacrum,  any  enlargement  of  the  uterus  is  liable 
to  be  uniform,  or  any  growth  is  located  anteriorly  in 
the  body  of  the  organ.  If  it  is  low  in  the  pelvis  and 
anterior  to  its  natural  location,  any  enlargement  of  the 
uterus  is  quite  likely  to  exist  in  the  fundus,  or  the 
uterus  is  retroverted.  If  it  is  anterior  to  its  normal 
position  and  is  crowded  well  up  behind  tlie  symjjhy- 
sis,  the  tumor  is  liable  to  be  hjcated  in  the  posterior 
wall  of  the  uterus,  very  low.  If  it  is  drawn  well  up 
posteriorly,   almost   if    not  ([uite    beyond    reach,   the 


21 


tumor  will  usually  be  found  in  the  anterior  uterine 
wall.  The  location  of  the  cervix,  however,  is  of  small 
importance  when  considered  alone. 

Bimanual  Examination. — By  combining  with  the 
digito-vaginal  examination,  external  j)ali)ation  with 
the  hand,  a  knowledge  of  the  general  contour  of  the 
uterus  can  be  at  once  definitely  obtained.  If  it  is  en- 
larged, that  fact  is  apparent;  if  there  are  any  in-egular 
projections  or  developments  from  any  portion  of  its 
walls  into  the  abdominal  cavity,  or  into  the  broad  lig- 
aments, they  can  be  recognized;  and  if  it  is  enlarged 
so  as  to  produce  a  prominent  tumor  a  knowledge  of  its 
source  of  development  can  usually  be  determined  by 
taking  into  consideration  its  relation  to  the  cervix.  If 
the  tumor  is  of  a  subperitoneal  variety,  its  relation 
with  the  cervix  and  uterine  body  will  indicate  its 
source  of  development.  If  the  cervix  is  thin  and 
stretched  over  a  projecting  mass,  j)rotruding  through 
it  from  the  uterine  cavity,  the  knowledge  of  a  uterine 
polypus  or  a  submucous  tumor  is  imparted.  The  sen- 
sation of  solidity  or  fluctuation  of  the  growth  is  usually 
satisfactorily  obtained  by  this  examination.  Thus, 
the  size,  contour,  consistence,  direction  of  develoi^- 
ment  and  variety  of  tumor  may  all  be  determined  by  a 
simple  bimanual  pelvic  examination. 

A  bimanual  examination,  however,  is  frequently 
unsatisfactory,  until  one  has  resorted  to  a  rectal  exam- 
ination, combined  with  the  abdominal  palpation,  and 
made  either  with  or  without  an  anesthetic.  This  lat- 
ter enables  one  to  examine  the  posterior  aspect  of  the 
uterus  much  higher  than  is  possible  per  vaginam.  and 
with  less  intervening  tissue.  An  anesthetic,  when 
given,  permits  of  a  much  more  prolonged  examination, 
renders  the  procedure  painless,  and  eliminates  the 
muscular  fixation  and  strain  which  is  inseparable  from 
an  examination  without  it.  The  abdominal  muscles, 
the  sphincters  of  the  rectum  and  vagina  are  relaxed, 
allowing  much  freer  and  more  complete  exi^loration. 
when  an  anesthetic  is  employed. 

Iiisfriimental    E.raniiiiafion.—Velyic    examination 


22 


tor  fibroids  is  often  not  complete  without  instrumen- 
tal examination.  While  a  speculum  is  not  often 
needed  as  a  direct  means  of  diagnosis,  in  these  cases, 
it  is  frequently  required  to  aid  in  determining  sec- 
ondary changes  which  may  have  occurred  in  the 
vagina  or  cervix  uteri.  It  may  also  be  employed  to 
exi^lore  the  cervix  where  the  vaginal  vault  has  been 
distorted  by  a  complicated  tumor,  before  vising  the 
uterine  sound.  The  uterine  sound  is  occasionally 
used  to  measure  the  uterine  canal.  It  may  be  em- 
ployed to  locate  the  canal  when  palpating  the  uterus 
for  the  i3urx30se  of  ascertaining  in  which  portion  of 
its  mass  a  tumor  is  situated.  And  it  will  also  give 
valuable  information  in  regard  to  the  location  and 
size  of  submucous  fibroids.  When  a  uterine  canal 
is  so  distorted  that  a  metal  sound  does  not  possess  the 
necessary  flexibility  to  traverse  its  course,  an  ordinary 
male  flexible  bougie,  with  a  bulbous  tip,  can  frequently 
be  successfully  insinuated  to  its  entire  depth,  and  give 
very  valuable  aid  in  diagnosis.  The  uterine  dilator  is 
an  important  instrument  in  diagnosing  the  condition 
of  the  interior  of  the  uterus.  It  enables  one  to  explore 
the  cavity  of  the  uterus  with  the  finger  and  thereby 
materially  assists  in  revealing  the  jDosition  and  char- 
acter of  submucous  fibroids. 

Abdominal  Pcdpatlon. — Abdominal  palpation  and 
auscultation  can  best  be  accomplished  with  the 
patient  under  the  influence  of  an  anesthetic.  By  pal- 
pation the  tumor  can  be  outlined;  any  subperitoneal 
projections  noted;  its  consistency  ascertained;  abscess 
or  presence  of  flluctuation  considered;  its  relations 
to  the  surrounding  organs  recognized  and  the  absence 
or  presence  of  adhesions  learned.  In  auscultation 
we  have  an  important  means  of  distinguishing  fetal 
heart  sounds  in  the  differential  diagnosis  between  a 
fibroid  tumor  and  a  natural  or  tubal  pregnancy. 

General  Examination. — In  the  general  examina- 
tion of  a  patient  wh(j  has  a  fibnnd  tumor,  points  of 
change  in  outlying  organs,  which  may  have  Ixh'Ji  the 
remote  result  of  the  tumor  and  which  may  have  an 


important  bearing  on  the  form  of  treatment  to  be 
adopted,  are  to  be  noted.  These  changes  may  be 
found  in  the  heart,  the  kidneys,  the  lungs,  the  diges- 
tive tract,  the  nervous  system  and  the  vascular  sys- 
tem; but  as  similar  changes  may  also  occur  from  any 
form  of  wasting  disease,  as  diagnostic  signs  they  are 
not  of  great  importance,  and  therefore,  their  consider- 
ation here  is  out  of  place. 

DIFFERENTIAL   DIAGNOSIS. 

We  are  often  called  upon  to  differentiate  between 
fibroids  and  the  following  conditions,  which  simulate 
them  to  a  puzzling  degree:  Ante-  and  retro-flexions, 
subinvolution  (metritis),  cancer,  floating  kidney, 
pregnancy,  tubal  pregnancy,  tubal  cysts  and  ovarian 
cysts. 

Ante-  and  retro-flexions  are  differentiated  from 
fibroids  by  the  comparative  smallness  of  the  uterus, 
and  the  lack  of  characteristic  hardness  of  the  fibroid. 
The  sound  clears  up  the  condition.  If  it  is  that  of  a 
normal  uterus  with  projecting  fibroid,  the  mass  will 
be  easily  palpated  in  front  or  x3osterior  to  the  sound, 
while  if  it  is  ante-  or  retro-version  the  sound  will  fol- 
low the  canal  to  the  center  of  the  flexed  fundus. 

Siihinvohition  (metritis)  is  distinguished  from  a 
fibroid  by  its  history,  by  its  symptoms  and  by  physi- 
cal signs.  The  history  of  subinvolution  is  that  of 
recent  child  bearing  or  miscarriages  with  subsequent 
endometritis,  while  a  fibroid  seldom  immediately  fol- 
lows pregnancy,  and  when  small  is  rarely  accompanied 
with  endometritis.  The  symptoms  of  the  two  con- 
ditions differ  in  the  amount  and  character  of  the  leu- 
corrhea,  being  profuse  in  chronic  metritis;  in  the 
amount  of  hemorrhage  at  menstruation,  being  profuse 
in  fibroids,  while  in  subinvolution  it  may  be  absent 
immediately  following  child  birth  for  several  months, 
and  of  a  more  normal  character  when  it  does  exist. 
Subinvolution  in  physical  signs  differs  from  a  fibroid 
in  being  of  a  softer  character,  resembling  the  normal 
uterus  in  being  of  uniform  contour  and  in  containing 


24 


no  distinct  centers  of  development.  With  a  condition 
of  subinvolution  will  almost  invariably  be  found  an 
accom]Danying  lacerated  cervix  and  frequently  a  lacer- 
ated perineum.  Finally,  uterine  curettement,  anti- 
septics and  a  restoration  of  a  torn  cervix,  will  cause  a 
SLibinvoluted  uterus  to  involute  to  its  natural  size, 
while  such  will  not  be  the  case  with  a  similar  treat- 
ment for  a  fibroid. 

A  cancer  (uncomplicated)  is  usually  easy  to  differen- 
tiate from  a  fibroid.  Microscopic  examination  should 
be  made,  if  practicable,  at  the  earliest  possible  date. 
An  uncomplicated  carcinoma  seldom  presents  a  large 
tumor.  If  it  is  of  the  cervix,  a  well-defined  ring 
shows  the  line  of  demarkation  between  it  and  the 
healthy  tissue.  An  offensive,  watery  discharge,  char- 
acteristic of  carcinomatous  degeneration,  is  of  diag- 
nostic value.  Carcinoma  of  the  body  of  the  uterus 
gives  rise  to  more  pain  than  a  fibroma.  It,  too, 
ulcerates  early,  giving  rise  to  the  afore-mentioned 
offensive  discharge.  The  cancer  cachexia  will  also 
aid  in  arriving  at  a  differentiation.  A  carcinomatous 
tumor  is  much  more  liable  to  give  rise  to  an  ascites 
than  a  fibroma. 

A  floating  kidneij  might,  under  exceptional  circum- 
stances, be  mistaken  for  a  subperitoneal  fibroid.  But 
its  position,  and  especially  the  discovery  of  its  place 
of  attachment,  would  dispel  all  doubt  of  its  being  a 
fibroid.  To  obtain  this  knowledge,  however,  might 
require  a  most  careful  abdominal  and  bi-manual 
manipulation. 

Normal  pregnancy  should  be  differentiated  from 
fibroid  tumors  first  by  bearing  in  mind  the  subjec- 
tive symptoms  of  the  two  conditions,  and  second 
by  physical  examination.  In  pregnancy  menstrua- 
tion almost  invariably  ceases;  in  fibroids  it  is  almost 
invariably  increased.  The  history  of  pregnancy  is 
definite  and  uniform,  with  a  given  size  of  tumor, 
while  with  fibroids  the  time  of  growth  varies  greatly 
with  tumors  of  the  same  size.  Morning  sickness  and 
breast  changes  are  classic   symptoms   of   pregnancy 


25 


which  rarely  occur  with  fibroids.  In  the  physical 
examination  the  pregnant  uterus  is  uniform  in  its 
development,  giving  a  soft,  semi-fluctuation  feel  on 
palpation.  Fibroids  are  frequently  irregular  in  out- 
line, and  on  palpation  appear  solid  and  often  present 
distinct  centers  of  hardness.  The  cervix  is  soft  and 
patulous  in  pregnancy,  and  the  neck  of  the  uterus 
sometimes  thin,  forming  a  decided  constriction,  while 
in  fibroids  the  cervix  is  unyielding  and  the  constric- 
tion of  the  neck  is  absent.  The  vagina  in  pregnancy 
is  blue,  a  rare  occun-ence  in  fibroids.  Finally,  as  the 
pregnancy  progresses  ballottement,  fetal  movements 
and  fetal  heart  sounds  remove  all  doubt  of  the 
condition. 

Tubed  py'egnani'n  would  rarely  be  mistaken  for  a 
fibroid  of  the  uterus.  It  presents  many  of  the  signs 
of  normal  pregnancy.  There  is  frequently  a  slight 
show  at  menstruation,  the  tumor  is  of  a  semi-fluctu- 
ating character,  and  lies,  as  a  rule,  to  the  right  or  left 
of  the  uterus;  while  a  subj^eritoneal  fibroid,  located 
in  the  position  usually  occupied  by  a  tubal  pregnancy, 
would  be  hard  and  unyielding.  In  tubal  pregnancy 
the  normal  uterus  may  be  distinguished  by  a  line  of 
demarkation  between  it  and  the  tumor. 

Ovaridii  cijsfs  are  usually  easy  to  distinguish  from 
fibroids  by  their  fluctuation;  by  the  lateral  delopment 
when  small;  by  the  slight  menstruation  accomx3anying 
them;  by  the  normal  size  and  depth  of  the  uterus  and 
by  the  absence  of  the  uterine  soufflle  distinguishing 
a  fibroid.  As  a  rule,  ovarian  cysts  are  of  a  rapid 
growth  and  give  a  short  history,  while  fibroids  are 
years  in  maturing. 


LECTURE  III. 


Treatment — General  Consideration — Medical 
Treatment. 


In  the  consideration  of  the  histology,  growth,  anat- 
omy, varieties  and  symptomatology  of  fibroids  of  the 
uterus  one  is  irresistibly  drawn  to  the  conclusion  that 
each  one  of  these  growths  is  a  law  unto  itself.  Such 
is  certainly  the  case  when  we  come  to  the  considera- 
tion of  treatment. 

A  fibroid  tumor  is  a  benign  growth.  The  principal 
symi^toms  arising  from  it  are  due  to  the  effect  of  its 
presence  upon  organs  associated  with  it  or  in  close 
proximity  to  it  rather  than  from  any  inherent  quali- 
ties. From  its  slowness,  in  the  majority  of  instances, 
to  produce  serious  symj^toms,  and  the  rarity  of  a  fatal 
termination  as  a  direct  result  of  it,  patients  are  with 
difficulty  aroused,  early  in  the  history  of  the  disease,  to 
adopt  radical  measures  for  relief.  Hence  innumerable 
symijtomatic  remedies  have  arisen,  each  for  a  brief  time 
having  enjoyed  the  reputation  of  specifics,  only  to  sink 
into  their  true  jjositions  as  soon  as  the  light  of  exper- 
ience had  shone  upon  them.  The  sim^jle  enumeration 
(jf  a  list  of  these  remedies  would  fill  a  long  chapter. 

The  remedies  for  fibroid  of  the  uterus  which  merit 
attention  must  be  considered  under  three  principal 
heads: 

1,  Medical  treatment. 

2.  Electrical  treatment. 
8.  Surgical  treatment. 

To  inclicate  when  each  of  the  above  methods  of 
treatment  coidd  be  employed  with  the  greatest  advant- 


27 


age  to  the  exclusion  of  the  other,  how  or  when  two  or 
more  could  be  combined  to  greatest  advantage  would 
be  a  task  which  would  necessitate  the  careful  analysis 
of  a  large  number  of  fibroid  cases,  together  with  all 
the  peculiarities  of  the  growths  with  their  surround- 
ings, the  temjoerament  and  the  physical  condition  of 
each  particular  patient  i^ossessing  the  tumor.  The 
most  that  can  be  attempted  is  to  describe  the  various 
remedies;  the  exact  physiologic  or  mechanical  effects 
of  each;  the  manner  of  administering  drugs;  the 
chemic,  mechanical  and  physical  effects  of  electricity, 
with  a  comprehensive  descri^Dtion  of  the  details  of  ap- 
plication; the  many  operative  procedures  including 
the  rationale  of  each  with  a  minute  technical  descrip- 
tion of  those  which  merit  attention;  and  finally  to 
show  wherever  each  remedy  is  es^jecially  adapted  to 
counteract  some  specific  condition  or  symptom  of  a 
fibroid  uterus. 

I  will  therofore  consider  each  grand  division  of 
treatment  in  detail  trusting  to  the  diagnostician  to  ajj- 
ply  the  remedies  as  the  indications  in  each  particular 
case  may  dictate. 

MEDICAL   TREATMENT. 

The  medical  treatment  of  fibroids  of  the  uterus  has 
played  an  im^^ortant  part  in  the  symptomatic  relief 
and  the  prolongation  of  life  of  those  afflicted  with  this 
dread  condition.  For  convenience  its  therapeutics 
may  be  divided  into  general  tonics,  alteratives,  seda- 
tives, astringents  and  special  uterine  tonics. 

General  Tonics. — Rapid  growth  of  a  fibroid  tumor 
and  a  condition  of  general  good  health  in  a  pa- 
tient seldom  exist  together.  So  true  is  this,  that  I 
have  learned  to  assure  i)atients  laboring  under  this 
disease  that  their  tumors  will  not  increase  in  size  rap- 
idly if  they  can  by  some  means  keep  themselves  in  a 
condition  of  natural  tonicity.  While  undoubtedly  the 
cause,  frequently,  of  the  general  lack  of  tone  is  the 
rapidly  growing  tumor,  1  believe  its  growth  may  be 
retarded  by  adopting  means   to  counteract  its  effect 


upon  the  patient.     While  the  tumor  with  its  accom- 
panying pain  and  loss  of  blood,  and  rapid  growth  must 
impair  general  health,  that  impaired  tone  of  necessity 
leaves  the  patient  with  still  less  resistance  to  with- 
stand the  onward  march   of  the  disease.     In   other 
words  the  results  of  the  rapid  growth  of  the  tumor 
does  in  turn  become  one  of  its  aids  to  still  more  rapid 
destruction.     Therefore  fibroid-tumor  patients  should 
be  abundantly  nourished.     The  loss  of  blood  should 
be  met  by  an  abundant  supply  of  wholesome  substan- 
tial food.     Bitter  tonics  such  as  quassia,  calumbo,  nux 
vomica  and  cinchona  should  be  administered  to  in- 
crease the  appetite.     Iron  should  be  administered  in 
a  form  to  be  readily  assimilated  in  order  to  improve 
the  blood.     The  patient    should  be  urged  to  drink 
milk  and  cream  between  the  regular  meals.     Prepared 
foods  both  of  the  nitrogenous  and  farinaceous  order 
should  be  employed  to  reinforce  the  ordinary  diet. 
Predigested  foods  may  be   found  of    service  if    the 
digestive  organs  fail  to  stand  the  strain  of  over  feeding. 
As  nerve  tonics  the  compound  syrup  of  the  hypo- 
phosites  with  small  doses  of  quinin,  strichnia  and  iron 
are  often  of  great  service.     Strychnia  in  gradually  in- 
creased doses  until  the  patient  takes  1-10  of  a  grain 
four  times  a  day,  I  consider  of  great  value  as  a  tonic 
in  these  cases.     The  dose  should  begin  at  1-40  or  1-60 
and  be  increased  gradually,  being  careful  to  avoid  un- 
pleasant constitutional    symptoms.     This   tones  the 
bowels,    acts  as  a  vaso-constrictor  tonic  everywhere, 
and  I  believe  acts  as  a  direct  tonic  to  the  muscular 
structure  of  the  uterus  itself,  while  it  undoubtedly  acts 
as  a  vaso-constrictor  to  the  uterus  and  tumor.     As  a 
direct  bowel  stimulant  and  laxative  aloin  with  strych- 
nia and  hyoscyamus  has  few  equals.     Cascara  sagrada 
may  take  the  place  of  the  above  as  an  alternative  lax- 
ative.    General  stimulating  baths  often  prove  benefi- 
cial tonics  to  fibroid  patients.     Sea  salt  baths,  \yarm  or 
cold  with  judicious  rubbing  to  establish  reaction,  are 
ohen  recommended.     Chloridof  sodium  baths  may  be 
employed  in  lieu  of  the  sea  salt  baths. 


29 


Hot  water  as  a  local  tonic,  employed  as  a  vaginal 
douche,  frequently  relieves  excessive  congestion  of 
the  uterus.  To  accomplish  this  object  the  water  must 
exceed  a  temperature  of  115  F.,  the  patient  should 
use  at  least  two  gallons  at  a  time  and  should  employ 
it  while  in  the  recumbent  position  on  the  back. 
Ohlorid  of  sodium  as  an  antiseptic  and  tonic  may  be 
dissolved  in  the  water —  3  to  the  pint.  Or  to  get  the 
advantage  of  an  astringent  the  same  amount  of 
powdered  alum  will  prove  of  advantage.  The  water 
must  be  hot.     Tepid  water  will  favor  hemorrhage. 

Change  of  air  from  the  sea  shore  to  the  mountains 
(not  too  high  an  altitude)  or  from  the  mountains  to 
the  sea  shore  often  imjjroves  health  and  retards  the 
growth  of  these  mysterious  tumors.  An  ocean  or  a 
European  trip  will  often  bring  a  remarkable  change 
for  the  better  in  these  unfortunate  cases.  Even  a 
slight  move  which  only  involves  a  change  of  routine, 
or  surrounding  the  i^atient  with  a  x^leasant  change  of 
companions  will  draw  them  away  from  themselves  and 
occasionally  give  them  just  the  impulse  which  they 
require  to  regain  the  lost  tone. 

Alteratives. — Arsenic,  muriate  of  ammonia,  mercury 
and  iodin  have  an  important  role  in  the  therapeutics 
of  uterine  fibroids. 

Arsenic  in  the  form  of  the  acid  or  in  Fowler's  solu- 
tion given  in  1-20  dose  of  the  former  and  in  5  drop 
doses  of  the  latter  immediately  following  each  meal 
will  often  act  as  a  i^owerful  alterative  tonic  in  these 
cases.  While  no  si^ecific  action  on  the  growth  of  the 
tumor  has  been  demonstrated,  its  general  efPects  are 
frequently  so  satisfactory  in  maintaining  a  general 
condition  of  tone  that  it  is  strange  it  has  not  run  the 
gauntlet  of  a  specific. 

Muriate  of  ammonia,  which  has  none  of  the  tonic 
properties  of  arsenic  and  while  inferior  in  alterative 
properties,  has  enjoyed  a  brief  trial  as  a  specific  for 
fibroids.  Its  principle  action,  it  seems  to  me,  lies  in 
the  direction  of  a  hepatic  stimulant.  By  favoring  a 
free  portal  circulation  its  action  in  relieving^  uterine 


30 

and  pelvic  congestion  must  be  obvious.  I  frequently 
employ  it  in  5  to  10  grain  doses  to  be  taken  in  one- 
half  glass  of  water  on  rising  in  the  morning.  It  acts 
in  this  way  as  a  very  gentle  stimulant  to  the  bowels 
and  may  be  used  as  a  substitute  for  saline  mineral 
water.  As  a  specific  for  fibroids,  however,  one  must 
not  place  upon  it  much  reliance. 

Mercury  in  the  form  of  blue  mass  or  calomel,  is  the 
most  valuable  alterative,  laxative  and  tonic  we  have  in 
all  pelvic  difficulties.     Its  efficiency  and  superiority 
as  a  laxative  lies  in  the  fact  that  it  is  our  best  hepatic 
stimulant.     It  unloads  the  portal  circulation,  relieves 
pelvic  congestions  and  favors  the   rapid  removal  of 
waste  products  from  the  pelvic  organs.     It  too,  possi- 
bly  from  the   same   reason,   increases   the   patient's 
desire  for  food,  aids  healthy  digestion,  favors  normal 
assimilation  and  gives  an  impetus  to  the  general  cir- 
culation.    My  esteemed  friend  and  teacher,  the  late 
Prof.    W.   H.    By  ford,    taught  me  the  value  of  this 
remedy  as  a  tonic,   when  properly  administered,  in 
gynecologic  practice.     As  a  laxative  the  blue  mass 
should  be  given  in  1  to  2  grain  doses  every  evening 
for  several  days,  then  to  be  omitted  for  a  like  number 
of  days.     Following  the  night  dose  the  next  morning 
should  be  administered  a  mild  saline  laxative,  either 
a  seidlitz  powder,  or  from  a  drachm  to  two  drachms  of 
granulated  citrate  of  magnesia  in  one-half  glass  of 
water.     As  an  alterative  tonic  it  may  be  given  in  half 
the  above  doses  extending  over  a  period  of  twelve  days. 
Calomel  is  a  convenient  form  for  administering  mer- 
cury as  a  tonic  and  alterative.     Triturated  with  sugar 
of  milk,  doses  of  1-30  of  a  grain  twice  or  three  times  a 
day  may  be  given  for  a   period  of  twelve  days.     An 
interval  of  twelve  days  should  then  elapse  before  re- 
continuing  the  drug.     The  bowels  should  be  kept  free 
with  saline  laxative  while  the  mercurials  are  in  use, 
and  care  should  be  exercised  to  avoid  the  unpleasant 
consequences  of  administering  hydrochloric  acid  co- 
incident with  the  drug. 

lodin  in  the  form  of  tincture  applied  to  the  cervix 


31 


of  a  fibroid  uterus  or  employed  as  an  applicatiuii  to 
the  mucous  membrane  has  been  much  extolled  as  a 
routine  treatment  for  fibroids.  As  an  alterative  its 
effects  on  a  fibroid  tumor  must  be  slight,  but  as  a 
stimulant  and  antiseptic  application  to  the  endome- 
trium of  an  endometritic  uterus  it  certainly  will  do 
good.  The  injection  of  iodiii  into  the  uterine  tumors 
will  scarcely  be  tolereted  as  a  rational  or  at  least  as  a 
desirable  treatment  at  the  present  day. 

Sedatives. — The  bromids,  the  coal  tar  antipyretics, 
chloral,  cannabis  indica,  hyoscyamus  and  opium  are 
sedatives  which  succeed  in  relieving  the  sutfering  of 
many  fibroid  patients  and  which,  when  judiciously 
employed  succeed  occasionally  in  tiding  them  over 
desperate  attacks  wdiich  would  prove  fatal  without 
their  assistance.  In  chronic  conditions  like  this  one 
we  are  considering,  no  physician  should  mistake  the 
temporary  effects  of  these  sedatives  for  eff'ects  of  a 
curative  agent.  Symptomatic  relief  only  can  we  hojje 
from  them  while  we  are  selecting  and  marshaling  our 
final  conquering  remedies. 

The  bromids  are  probably  as  safe  and  as  enduring 
as  any  mild  sedative,  where  irritability  and  general 
nervousness  characterize  the  patient's  suffering 
instead  of  actual  localized  i^ain.  Bromid  of  potas- 
sium, ammonia  and  sodium  mixed  in  solution  given 
in  doses  containing  10  grains  of  each,  the  doses  given 
at  intervals  of  four  to  six  hours,  until  nervousness  is 
allayed  and  sleep  obtained,  is  a  favorite  method  of 
mine  of  administering  this  drug.  Frequently  the 
above  combination  given  as  a  dose  at  bedtime  will 
accomplish  good. 

Antifebrin,  johenacetin  and  antipyrin  I  have  found 
of  value  in  relieving  severe  menstrual  pain  accom- 
panying fibroids.  By  giving  them  in  their  apjjropriate 
doses  at  intervals  of  two  to  four  hours  during  the  pain- 
ful period  of  the  menstruation  frequently  complete 
relief  is  obtained. 

Chloral  is  a  favorite  hospital  remedy  of  mine.  I 
employ  it  for  the  uterine  pain  which  accompanies 


32 


menstraation  exclusively — not  as  a  steady  remedy. 
The  favorite  method  of  administering  it  is  to  instruct 
the  nurse  to  give  20  to  30  grains  in  three  ounces  of 
water  as  a  small  rectal  enema  not  oftener  than  once  in 
four  hours  for  severe  pain  or  sleeplessness.  It  does 
not  affect  the  stomach  when  given  in  this  manner, 
and  the  method  of  administering  the  remedy  serves  to 
make  it  unpopular  to  the  patient.  In  fact,  an  effort 
is  made  to  keep  the  patient  in  ignorance  of  the  con- 
tents of  the  enema. 

Cannabis  indica  as  a  remedy  for  pain  in  menstrual 
difficulties  is  one  which  I  have  never  learned  to 
appreciate.  The  remedy  is  so  uncertain  and  variable 
in  its  actions  that  I  usually  resort  to  something  upon 
which  I  have  greater  reliance.  If  a  pure  article  can 
be  obtained  a  pleasant  combination  of  cannabis  indica 
in  extract  combined  with  ergot  and  valerinate  of  qui- 
nin  for  the  pain  of  fibroid  monorrhagia  may  be 
employed  with  advantage.  The  extract  of  cannabis 
indica  in  from  J  to  |  of  a  grain,  the  ergotin  in  from  J 
to  1  grain,  and  the  valerinate  of  quinin  in  2  grain 
doses,  makes  a  powerful  uterine  tonic,  the  cannabis 
indica  and  the  valerinate  modifying  the  pain  which 
otherwise  would  be  aggravated  by  the  necessary 
effects  of  ergot  and  quinin. 

Hyoscyamus,  belladonna  and  stramonium  are  valu- 
able sedative  remedies  to  employ  as  alternatives  in  the 
long  medical  treatment  which  one  is  often  obliged  to 
conduct  before  these  patients  decide  to  have  radical 
means  adojjted.  While  one  sedative,  hypnotic  or  anti- 
irritant  remedy  after  another  is  being  employed  these 
drugs  will  often  give  surprising  aid  as  a  temporary 
su}).stitute  for  remedies  which  for  prudential  reasons 
we  feel  should  be  discontinued.  The  active  principle 
hyoscyamin  or  atropin  may  be  given  in  solution  in 
apijropriate  doses;  or  may  be  given  in  the  small  gran- 
ules which  are  so  accurately  compounded  by  the  large 
[nanufacturers  of  pills.  I  frequently  combine  these 
drugs  with  the  valerinate,  the  two  making  very  effec- 
tual sedatives  or  anti-nervous  remedies. 


38 


Gelsemium,  valerian,  and  asafetida  are  very  valu- 
able drugs,  which  can  be  employed  with  success  in  the 
treatment  of  fibroids.  Extract  of  gelsemium,  com- 
bined with  valerinate  of  quinin,  zinc  and  iron,  acts 
as  a  very  reliable  aid  as  a  mild  anti-neuralgic,  while 
in  asafetida  we  have  a  remedy  which  the  physician 
could  ill  afford  to  lose.  Good  full  doses  of  asafetida, 
4  to  8  grains,  four  times  a  day  has  carried  many  a 
nervous,  sleepless,  hysterical  woman  successfully 
through  what  otherwise  would  have  been  a  painful 
menstrual  period. 

Opium  is  a  dangerous  remedy  to  employ  for  the 
pain  of  fibroids.  The  remedy  is  so  prompt  and  effi- 
cient with  the  majority  of  patients  that  it  is  an  easy 
matter  for  a  dangerous  habit  to  be  contracted,  inas- 
much as  the  difficulty  is  a  chronic  and  constantly 
reverting  one.  If  in  desperate  cases  it  is  considered 
wise  to  employ  the  drug  temporarily,  it  should  be 
presented  by  the  physician  and  given,  if  possible, 
without  the  patient  becoming  aware  of  the  contents 
of  the  dose.  A  condition  serious  enough,  however,  to 
demand  the  use  of  opium  should  also  demand  some 
permanent  radical  means  of  cure. 

Astvingents. — Local  astringents  include  such  drugs 
as  may  be  employed  with  curative  benefit  by  applica- 
tion to  the  mucous  membrane  of  the  uterus  or  by  ap- 
plication to  the  neck  of  the  womb  through  the  vagina. 
Local  astringents  may  be  employed,  too,  for  the  tem- 
porary effect  they  may  have  on  the  secretions  of  the 
uterus  or  for  the  direct  curative  effect  they  may  exert 
when  applied  to  the  mucous  membrane  of  the  fibroid 
womb.  When  the  astringents  are  applied  to  modify 
temporarily  the  secretions  of  the  uterus,  for  instance 
the  excessive  blood  flow,  it  is  best  applied  on  tampons. 
Alum  is  cheap  and  one  of  the  safest  and  most  efficient 
astringents  to  use  in  this  way.  Wicking,  or  strips  of 
gauze,  or  cotton  tampons  may  be  prepared  and  kept 
for  emergencies,  by  dipping  them  into  a  20  per  cent, 
solution  of  alum  in  hot  water  and  then  evaporating 
the  water  of  solution  by  exposure  to  the  air.     This 


34 


leaves  the  alum  thickly  deposited  in  the  interstices  of 
the  material.  It  is  only  necessary  then  to  apply  the 
tampon  directly  to  the  bleeding  cavity,  allowing  the 
fluids  of  the  cavity  to  dissolve  the  alum,  or  it  can  be 
placed  in  warm  water  immediately  before  applying. 
Excessive  bleeding  from  the  uterus  which  fails  to  yield 
to  other  remedies  will  seldom  fail  to  be  controlled  by 
well  placed  uterine  tampons  well  saturated  with  alum. 
Wicking  or  strips  of  gauze  without  knots  is  the  best 
material  to  employ.  The  patient  should  be  placed  in 
Sims'  position^  the  neck  of  the  uterus  grasped  with  a 
strong  tenaculum,  so  as  to  expose  the  canal,  then  by 
means  of  a  bulbous-pointed  uterine  sound,  the  material 
should  be  systematically  packed  to  the  bottom  of  the 
uterus.  Only  where  the  hemorrhage  is  alarming  is 
this  procedure  necessary.  In  ordinary  bleeding  a  well- 
placed  vaginal  tampon  alone  is  necessary.  For  vagi- 
nal tamiDons,  Byf ord  recommends  comj)ressed  sponges 
saturated  with  alum.  They  are  made  by  taking  a  fine 
sponge,  large  enough  to  fill  the  vagina,  passing  a  strong 
string  through  the  center  to  aid  in  its  removal,  and 
then  after  dipping  it  in  the  solution  of  alum,  well 
winding  it  with  twine  from  one  end  to  the  other,  com- 
pressing it  into  as  small  a  space  as  possible.  The 
twine  should  so  comjjress  the  sponge  as  to  make  it 
assume  an  elongated  form.  It  should  then  be  laid 
aside  and  permitted  to  dry.  Several  of  these  should 
be  kept  on  hand  by  the  patient,  she  having  been  pre- 
viously instructed  how  to  employ  them.  After  com- 
pression and  drying  it  will  be  of  small  size,  and  such 
shape  that  it  can  be  easily  introduced  into  the  vagina, 
while  the  moisture  of  the  parts  will  soon  cause  it  to 
expand  into  an  efficient  tampon. 

Astringents  when  ai)plied  to  the  mucous  membrane 
of  the  uterus,  are  applied  ordinarily  for  the  curative 
effect  they  may  exert  on  the  inflamed  endometrium. 
For  this  purpose  the  tincture  of  the  chlorid  of  iron 
is  a  poxmlar  astringent.  I  liave  employed  with  bene- 
fit a  10  per  cent,  solution  (jf  chlorid  of  zinc  in  gly- 
cerin and  water.     Varying  strength  solutions  of  nitrate 


35 


of  silver  have  been  employed.  This  is  objectionable, 
however,  because  of  the  indelible  stain  produced  by 
it.  There  is  such  a  large  variety  of  well-known 
astringents  which  may  be  employed  for  this  purpose 
that  it  seems  like  needless  waste  of  time  to  enumerate 
them. 

The  application  to  the  mucous  membrane  should  be 
made,  after  the  cervix  has  been  exposed,  by  means 
of  a  flexible  applicator  wrapped  with  cotton.  The 
canal  should  first  be  wiped  free  •  as  possible  of  all 
secretion  by  means  of  the  applicator  and  cotton  and 
when  that  is  accomplished  the  mucous  membrane 
should  be  thoroughly  painted  with  the  astringent  by 
passing  the  ajjplicator,  well  wound  with  absorbent 
cotton,  and  saturated  with  the  drug,  to  the  bottom  of 
the  uterus. 

General  Astringents. — Of  the  astringents  which 
reach  the  uterus  and  modify  uterine  hemorrhage  when 
given  internally  I  know  of  none  which  compares  with 
hydrastis  canadensis.  It  contracts  the  blood  vessels 
and  modifies  the  hemorrhage.  It  is  so  efficient  that 
one  is  led  to  believe  that  it  has  a  direct  contractile 
effect  upon  the  muscular  walls  of  the  uterus  and 
tumor.  While  it  acts  as  an  astringent  with  s]jecial 
predilection  for  the  uterus  it  also  is  efficient  as  a  bit- 
ter tonic.  The  fluid  extract  may  be  given  in  doses  of 
a  third  to  one-half  a  drahm  three  or  four  times  a  day. 
I  frequently  combine  the  solid  extract  with  ergot  in 
grain  doses  of  each  in  form  of  capsules,  one  three  or 
four  times  a  day.  This  drug  actually  seems  to  possess 
a  curative  effect  not  only  in  diminishing  the  amount 
of  the  blood  discharge  but  also  in  decreasing  the  size 
of  the  tumor.  When  employed  to  modify  hemoiThage 
it  should  be  given  in  good  maximum  doses  of  one- 
half  to  three-fourths  drachm  of  the  fluid  extract 
three  or  four  times  a  day  during  menstruation.  If  it 
is  to  be  employed  as  a  direct  curative  agent  it  can  be 
more  conveniently  and  elegantly  administered  in  cap- 
sale  form  as  already  indicated  either  alone  or  com- 
bined with  other  uterine  tonics. 


36 


Tincture  of  cannabis  indica  in  from  four  to  ten 
drop  doses  given  during  the  approach  and  continuance 
of  menstruation  not  only  modifies  irritation  but  also 
acts  as  an  astringent  and  hemastatic. 

Special  uterine  fonics. — Ergot  has  occupied  such  a 
conspicuous  and  important  role  in  the  treatment  of 
fibroids  of  the  uterus  that  I  deem  it  advisable  to  devote 
a  special  article  to  its  consideration. 

The  foregoing  article  can  be  briefly  summarized  as 
follows : 

1.  The  medical  therapeutics  of  fibroids  of  the  uterus 
are  divided  into  general  tonics,  alteratives,  sedatives, 
astringents  and  special  uterine  tonics. 

2.  General  tonics:  Judicious  and  systematic  feed- 
ing; bitter  tonics  including  quassia,  calumba,  nux 
vomica  and  cinchona;  iron;  prepared  foods  of  all 
kinds.  Nerve  tonics:  The  hypoiDhosphites;  strichnia 
and  manganese.  Bowel  tonics:  Aloin  and  cascara 
sagrada.  General  stimulants:  Hot  salt  baths;  sea  salt 
baths,  w^arm  or  cool;  massage.  Local  tonics:  Hot 
vaginal  douches.  Climate :  Change  of  residence,  travel 
and  ocean  voyage. 

3.  Alteratives:  Arsenic;  muriate  of  ammonia;  mer- 
cury; iodin. 

4.  Sedatives:  The  bromids;  the  coal  tar  antipyretics; 
chloral;  asafetida;  valerian;  gelsemium;  hyoscyamus; 
opium. 

5.  Astringents-  Local,  alum;  chlorid  of  zinc;  prepa- 
ration of  iron.  General  astringents:  Hydrastis;  can- 
nabis indica. 

6.  Special  uterine  tonic:  Ergot. 


LECTURE  IV. 


Ergot. 


The  physiologic  actums  of  ergot  are  accounted  for 
by  its  effects  upon  uustripecl  muscular  fiber.  It  con- 
tracts blood  vessels  everywhere,  thereby  increasing 
the  blood  tension.  The  uterus,  formed  as  it  is  by  an 
enormous  x^roportion  of  smooth  muscular  structure,  is 
particularly  susceptible  to  the  peculiar  action  of  ergot. 
It  acts  upon  the  uterus  in  four  ways: 

1.  It  decreases  the  whole  bulk  of  the  organ  by  pro- 
ducing a  steady  tonic  contraction  of  all  its  muscular 
fibers;  2,  it  decreases  the  whole  bulk  of  the  organ  by 
decreasing  the  amount  of  blood  in  its  walls,  as  a  result 
of  contracting  its  blood  vessels;  3,  by  decreasing  the 
amount  of  blood  in  the  uterus  (by  contracting  its 
muscular  bulk  and  by  contracting  its  blood  vessels) 
it  modifies  materially  its  nutrition  and  decreases  the 
amount  of  the  menstrual  flow  of  blood;  4,  when  given 
in  large  doses  it  not  only  produces  tonic  contractions 
of  the  muscular  fibers  of  the  uterus,  but,  by  insti- 
tuting clonic  contraction  of  its  fibers,  expulsion  of 
natural  and  foreign  bodies  from  its  walls  and  cavity 
is  effected. 

Upon  these  thoroughly  demonstrated  effects  of 
ergot  has  grown  m\)  a  rational  and  very  successful 
medical  treatment  of  fibroids  of  the  uterus.  Before 
surgery  and  electricity  found  favor  in  the  experience 
of  gynecologists,  as  remedies  which  did  their  work 
with  greater  expedition,  if  not  with  more  certain 
results,  ergot  for  many  years  was  de]  ended  upon,  not 


38 

only  as  a  symptomatic  remedy  tor  fibroids  but  as  a 
valuable  curative  agent. 

The  mode  of  action  of  ergot  on  fibroids  of  the  uterus 
when  considered  in  the  light  of  its  effect  upon  the 
normal  uterus,  can  be  easily  understood. 

An  interstitial  fibroid  is  affected  by  ergot  in  three 
ways :  First,  by  the  pressure  exerted  on  the  uniformly 
distributed  fibro-myomatous  fibers  by  the  normal  ute- 
rine tissue  which  everywhere  surrounds  them  which 
has  been  stimulated  to  firm  contraction  by  the  drug; 
second,  by  a  tendency  of  the  hypertrophied  fibro- 
myomatous  fibers  themselves  to  firmly  contract  under 
the  abnormal  stimulant.  The  result  of  this  pressure 
upon  the  abnormal  tissue  is  to  produce  atrophy.  A 
third  effect  of  ergot  upon  an  interstitial  fibroid  of  the 
uterus  which  favors  its  atrophy  and  decreases  uterine 
hemorrhage,  is  the  diminution  of  its  blood  supply 
from  the  contraction  of  its  arterioles. 

Intramural  fibroids  are  also  affected  in  three  ways: 

1,  pressure  atrophy  from  the  firm  contractions  of 
the  normal  uterine   tissue   surrounding  the   masses; 

2,  atrophy  and  decrease  of  uterine  hemorrhage,  dim- 
inution of  their  blood  supply  as  a  direct  result  of 
contraction  of  the  arterioles;  3,  a  tendency  for 
them  to  be  expelled  from  the  walls  or  the  uterus  in 
the  direction  of  least  resistance,  as  a  result  of  the 
persistent  contraction  of  the  normal  uterine  tissue  sur- 
rounding the  masses. 

Huhmucous  fibroids,  which  are  but  a  form  of  the 
intramural  variety,  are  influenced  in  the  same  manner 
by  ergot  as  is  the  simple  intramural,  while  its  cure  is 
also  sometimes  eff'ected  by  the  expulsive  contractions 
of  the  uterus,  which  force  it  first  beneath  the  mucous 
membrane  as  a  pedunculated  mass,  and  finally  expel 
it  bodily  from  its  cavity. 

Hub  peritoneal  fibroids,  which  also  are  but  a  form  of 
the  intramural  variety,  are  influenced  practically  the 
same  as  that  class,  except  that  the  influence  of  mus- 
cular contracti(jn  diminishes  as  the  tumors  become 
more    subperitoneal  and   more  pedunculated.     The 


39 


expulsion  of  the  subperitoneal  variety  is  not  aided  by 
the  expulsive  power  of  the  uterus. 

INDICATIONS  FOR  ERGOTIN  TREATMENT. 

The  most  favorable  case  for  ergotin  treatment  in 
which  a  complete  cure  may  be  looked  for  is  the  intra- 
mural variety  which  consists  of  one  or  few  centers  of 
development,  with  these  centers  situated  in  close 
proximity  to  the  mucous  membrane.  The  uterus  in 
such  a  case  is  considerably  enlarged,  the  canal  is  long 
and  tortuous,  the  symjjtom  of  uterine  hemorrhage  is 
conspicuous  and  the  normal  muscular  tissue  of  the 
uterus  is  hypertrophied.  Ergot  given  in  such  a  case 
in  large  doses,  continued  for  some  weeks,  will  cause 
the  hypertrox^hied  muscles  of  the  uterus  to  contract 
and  to  gradually  squeeze  the  fibromatous  center  first 
toward  the  mucous  membrane,  then  beneath  the 
mucous  membrane  and  finally  into  the  uterine  cavity, 
where  the  uterine  expulsive  pains  will  effect  its  deliv- 
erance. The  enucleation  of  such  a  tumor  can  be 
materially  assisted,  as  it  should  be,  by  incising  its 
capsule  as  it  begins  to  protrude  beneath  the  mucous 
membrane. 

When  such  a  center  or  centers  are  expelled  effectu- 
ally the  uterine  pains  will  cease,  the  hemorrhage  will 
lessen  and  the  uterus  will  soon  be  found  of  normal 
size. 

Pediculated  fibroids  are  somewhat  differently  af- 
fected by  ergot  when  they  are  submucous  than  when 
subperitoneal.  If  the  uterus  is  considerably  enlarged 
and  the  normal  muscular  tissue  of  the  organ  is  hyper- 
trophied, there  is  some  hope  that  the  pedicle  of  a  sub- 
peritoneal pediculated  fibroid  will  gradually  become 
restricted  by  the  uterine  contractions,  the  nourish- 
ment of  the  tumor  supplied  by  the  pedicle  be  dimin- 
ished thereby,  and  as  a  consequence  a  gradual  atrophy 
of  the  stranded  mass.  While  this  maij  occur  with  a 
subperitoneal  tumor,  it  may  be  counted  on  much  more 
surely  if  the  tumor  is  submucous. 

In  the  submucous  pedicxdated  fibroid  the  nourish- 


40 


ment  oi  the  pendant  tumor  is  not  only  impaired  by 
the  constriction  of  its  pedicle's  base,  but  the  expul- 
sive effort  of  the  uterus  itself  will,  in  its  effort  to  rid 
itself  of  the  foreign  body,  stretch  and  thin  its  pedicle 
until  its  bloodvessels  are  eradicated  and  its  tumor 
decre^.ses  from  starvation.  Sometimes  the  decrease  is 
only  partial  from  some  small  amount  of  blood  still 
gaining  access  to  the  mass.  Under  either  circum- 
stances it  remains  but  to  catch  the  growth  in  a  forceps 
and  to  twist  it  from  its  weak  stem.  The  uterus  then 
contracts  to  its  normal  state  if  there  are  no  other  cen- 
ters of  develoiDment. 

A  true  intevM it ial  fibroid  is  seldom,  if  ever,  cured 
by  ergot.  While  the  muscular  fibers  of  the  uterus 
are  often  enormously  developed,  there  are  no  distinct 
masses  for  them  to  work  on  when  stimulated  to  con- 
traction; nothing  for  them  to  get  rid  of  but  their 
fellow  fibers.  In  this  they  may  partially  succeed  by 
producing  atrophy  of  one  anotlaer  by  pressure,  and 
by  lessening  the  blood  supply  by  contracting  their 
blood  vessels.  This,  however,  experience  has  taught 
us  is  a  slow  method  of  diminishing  a  fibroid  tumor. 
If  large  doses  are  systematically  administered  for  a 
long  time  menorrhagia  can  often  be  materially  bene- 
fited, but  seldom  permanently  relieved. 

Prof.  W.  H.  By  ford,  who  was  the  first  in  this  coun- 
try to  publish  results  from  the  treatment  of  fibroid 
tumors  by  ergot,  after  Hilderbrandt  had  published  his 
work  in  this  line  in  Europe,  begins  his  chapter  on  the 
subject  asfolhjws:  "  1.  When  properly  administered, 
ergot  frequently  greatly  ameliorates  some  of  the 
tr<jublesome  and  even  dangerous  symptoms  of  fibrous 
tumors  of  the  uterus,  e.  g.,  hemorrhage  and  copious 
leiicorrhea.  2.  It  often  arrests  their  gn^wth  and  checks 
hemorrhage.  3.  In  many  instances  it  causes  the  ab- 
sorption of  the  tumor,  occasionally  without  giving  tlie 
patient  any  inconvenience;  at  other  times  removal  of 
the  tumor  by  aV)sori)tion  is  attended  by  painful  con- 
tractions and  tenderness  of  the  uterus.  4.  By  induc- 
ing uterine  contraction  it  causes  the  expulsion  of  the 


41 

polypoid  vdriety.     5.  In  the  same  way  it  causes  the 
disruption  and  discharge  of  the  submucous  tumor." 

METHOD  OF  ADMINISTRATION. 

According  as  the  physician  seeks  a  mild  or  an 
active  effect  o£  ergot  should  he  regulate  his  dose.  In 
the  first  instance  ergot  is  administered  in  doses  just 
sufficiently  large  to  maintain  a  tonic  contraction  of 
the  arterioles  and  of  the  uterine  tissue  without  pro- 
ducing  the  pain  which  is  a  constant  accompaniment 
of  the  violent  clonic  contractions  of  the  uterus.  When 
the  active  effects  of  ergot  are  sought,  large  and  often 
repeated  doses  are  administered  in  such  a  manner  as  to 
obtain  prompt  and  full  physiologic  effects  of  the  drug. 

When  mild  effects  are  sought  ergot  can  usually  be 
administered  by  the  stomach.  For  this  purpose  I 
usually  employ  the  purified  extract  called  ergotin, 
administered  in  the  form  of  capsules.  Capsules  con- 
taining from  three  to  five  grains  each,  given  at  inter- 
vals of  four  to  six  hours,  will  seldom  disagree  with 
the  patient.  Intervals  of  six  hours,  unless  active 
effects  are  desired,  are  short  enough.  Frequently  the 
dose  of  five  grains  will  be  too  large  for  a  simple  tonic 
potion.  I  frequently  give  the  ergotin  in  two-grain 
doses  in  capsule  cmbined  with  one-fourth  of  a  grai  n 
of  the  extract  of  nux  vomica,  distributing  the  doses 
so  that  they  are  taken  before  meals  and  at  bedtime. 
Ergot  can  be  given  with  good  results  in  mild  doses  in 
rectal  suppositories.  Occasionally  it  will  be  tolerated 
in  the  form  of  the  fluid  extract  by  the  mouth.  There 
is  very  little  occasion,  however,  if  a  patient  can  take 
a  capsule,  for  submitting  them  to  this  nauseating  dose. 

When  we  desire  to  obtain  the  active  effects  of  ergot 
some  management  is  necessary  in  order  to  get  into 
the  system  of  an  ordinary  woman  a  sufficient  dose  of 
the  drug,  without  at  the  same  time  disturbing  the 
functions  of  the  digestive  organs. 

Ergotin  in  capsules,  in  five  and  ten  grain  doses, 
frequently,  will  be  tolerated  by  the  stomach  almost 
indefinitely.     Occasionally  a  much  smaller  dose  will 


42 


be  utterly  rejected.  Ergotin  then  may  be  adminis- 
tered in  eight  to  ten  or  fifteen  grain  rectal  supposito- 
ries. The  physiologic  effects,  in  a  decided  manner, 
may  frequently  be  obtained  in  this  manner.  The 
lower  bo\N'el  should  be  kept  clear  of  all  fecal  matter 
and  the  suppository  placed  high.  They  may  be.  ad- 
ministered as  often  as  every  six  hours.  Suppository 
tubes  may  be  employed  to  advantage  for  the  purpose 
of  x^lacing  the  suppository  mixture  higher  in  the 
bowel  than  is  possible  with  the  ordinary  suppository. 
Small  rectal  enemas  of  the  fluid  extract  may  be  em- 
ployed as  a  means  of  obtaining  the  active  effects  of 
the  drug. 

Hypodermic  injections  of  fluid  preparations  of 
ergot  succeed  in  obtaining  the  promptest  and  most 
efficient  physiologic  effects  of  the  drug,  while  they 
possess  the  objection  of  producing  not  a  little  pain  and 
occasionally  abscesses.  The  abscesses  may  be  avoided 
by  attention  to  aseptic  principles,  and  the  pain  can  be 
materially  avoided  by  selecting  non-sensitive  portions 
of  the  skin  combined  with  deep  injections,  and  by  the 
employment  of  a  mixture  containing  one  of  the  less 
harmful  sedatives,  as  chloral  hydrate  or  belladonna. 

Pozzi  recommends  the  following  formula  for  hypo- 
dermic use: 

R .        Ergotin gr.  Ixxv 

Chloral  hydrate S^-  ?.X 

Aqua  distil    ....  ad  §  ill 

Sig.      Twelve  minims  injected  daily. 

W.  H.  By  ford  says:  "Most  American  practitioners 
now  use  Dr.  Squibb's  prei)aration  (purified  solid 
extract),  some  of  them  by  dissolving  it  in  pure  water, 
while  others  add  to  the  water  a  small  amount  of  pure 
glycerin.  Dr.  Squibb  recommends  a  solution  of  this 
extract  as  follows:  Dissolve  two  hundred  grains  of 
the  extract  in  two  hundred  and  fifty  minims  of  water 
by  stirring;  filter  the  solution  through  i)aper,  and 
make  up  to  three  hundred  minims  by  washing  the 
residue  on  the  filter  with  a  little  water.  Each  minim 
of  this  solution  represents  six  grains  of  ergot  in  pow- 


43 


der.  Of  this  solution  from  ten  to  twenty  minims  are 
injected  once  daily  or  once  in  two  days.  This  is  the 
only  preparation  I  have  used  in  hyj^odermic  injections, 
and  I  believe  it  is  the  best  we  can  at  present  j^rocure." 
It  has  been  several  years  since  I  have  used  ergot 
hypodermically ;  the  last  that  I  did  employ  was  pre- 
pared practically  as  given  in  Dr.  Byford's  formula. 

DURATION  OF  TREATMENT. 

As  ergot  at  best  can  scarcely  be  termed  an  actual 
curative  agent  for  fibroid  of  the  uterus  (except  in 
rare  instances)  it  follows  that  the  duration  of  treat- 
ment must  vary  entirely  with  the  case  in  hand,  the 
results  sought,  and  the  judgment  of  the  particular 
physician  treating  the  case. 

If  the  case  is  an  ordinary  bleeding  interstitial 
fibroid  of  uniform  contour,  in  which  there  seems  to  be 
no  sub-mucous  projections  which  w^e  might  hope  to 
expell  by  means  of  heroic  doses  of  ergot,  small  doses 
of  from  two  to  five  grains  each  of  ergotin  in  capsules 
might  be  given  three  times  a  day  for  several  months. 
The  effect  sought  being  a  general  vasomotor  tonic 
action  wdth  a  special  predilection  for  uterine  vaso- 
constriction, and  uterine  shrinkage  due  to  long  con- 
tinued tonic  muscular  contraction  of  the  organ.  The 
subjective  results  being  diminution  of  the  menstrual 
discharge,  pressure  symptoms  lessened  and  an  im- 
provement in  flesh  and  strength. 

If  the  case  is  a  sub-mucous  fibroid  in  which  the 
attempt  is  to  be  made  to  accomplish  the  expulsion  of 
the  mass  by  contraction  of  the  uterus  stimulated  by 
heroic  doses,  ergotin  in  form  of  large  suppositories, 
or  better,  in  hypodermic  injections  will  be  adminis- 
tered until  the  result  is  accomplished.  When  the 
tumor  is  expelled  the  remedy  is  immediately  suspended. 

If  the  case  is  one  of  interstitial  bleeding  fibroid  and 
the  object  is  to  control  or  to  modify  the  monthly  flow 
of  blood,  ergot  in  good  full  doses,  either  by  capsules, 
suppository,  or  hypodermic  injections,  should  be  com- 
menced a  few  days  before  the  menstrual  period,  and 


44 


be  continued  until  the  flow  has  ceased,  when  it 
can  be  discontinued  until  a  week  before  the  next 
menstruation. 

So  that  one  must  take  into  consideration  the  phys- 
iologic effects  of  the  drug,  under  its  varying  doses, 
take  into  consideration  the  variety  and  character  of 
the  tumor  and  with  these  well  in  hand  he  must  exer- 
cise his  judgment  in  making  his  application  in  each 
individual  case. 

RESULTS. 

The  results  obtained  in  the  treatment  of  fibroid 
tumors  of  the  uterus  by  ergot,  depends  much  upon 
the  sincerity  and  peristency  of  the  physician  who  is 
conducting  the  treatment.  If  he  is  sincerely  desirous 
of  exhausting  the  resources  of  ergot  in  these  cases 
before  resorting  to  more  radical  means,  or  better,  if  he 
is  oi^posed  to  any  more  radical  treatment  than  the 
ergot  treatment  for  fibroids,  combined  of  course  with 
rational  hygienic  and  general  tonic  treatment,  he  will 
be  sure  to  benefit  a  large  percentage  of  his  cases,  and 
possibly  a  small  i^ercentage  will  become  actually  cured. 
Unfortunately  now,  in  the  light  of  the  more  precise 
and  comparatively  safe  surgical  procedures,  and  the 
more  accurate,  agreeable,  if  not  more  efficient  electri- 
cal treatment,  the  slower,  more  disagreeable  and  pain- 
ful medical  treatment  by  ergot,  is,  I  am  afraid,  too 
much  slighted  by  practitioners.  As  the  treatment  is 
old,  but  one  of  the  meritorious  relics  of  pre-surgical 
days,  I  can  only  indicate  its  real  value  by  quoting  some 
of  the  statistics  gathered  by  those  who  practiced  it 
enthusiastically  if  n(^t  almost  exclusively. 

One  of  the  last  statistical  papers  of  value  written  on 
this  subject  was  one  read  at  the  Ninth  International 
Medical  Ofjngnjss,  held  at  Washington  in  1887,  by 
Prof.  D.  T.  Nelson,  of  Chicago.  In  that  paper  he 
reported  15JJ  cases  treated  by  ergot,  representing  the 
reports  of  about  one  hundred  physicians.  The 
method  of  administering  the  drug  was  seldom 
described  by  tlie  reporters.  As  a  circular  letter  was 
sent  to  over  4,000  physicians,  and  that  the  100  phy- 


45 


sicians  replying  almost  invariably  reported  suc- 
cesses, there  may  be  grounds  for  believing  that  had 
many  more  reported  the  answer  might  not  have  been 
so  uniformly  favorable.  The  following  is  a  brief  sum- 
mary of  the  153  cases,  as  given  in  Dr.  Nelson's  words: 

"The  small  number  of  cases  as  not  affected  by  ergot 
is  quite  remarkable,  but  two  of  the  153  cases.  All 
the  153  cases  were  benefited  by  the  ergot,  more  or 
less,  except  these  two.  Seventy-nine  were  cured, 
tumor  absorbed  or  expelled.  In  61  other  cases  the 
tumors  are  smaller  and  their  growth  controlled,  and 
there  is  every  promise,  with  ergot,  and  perhaps  with- 
out, that  they  will  not  again  endanger  life."  There 
were  11  deaths  in  the  153  cases.  "In  cases  12,  13  and 
17  ergot  seemed  to  control  the  disease,  and  had  it  been 
continued  favorable  results  were  to  be  expected.  Cases 
16  and  29  died  of  septicemia  after  the  expulsion  of  the 
tumor;  such  cases  in  future  it  is  hoped,  by  improved 
methods,  we  may  usually  save.  Cases  53  and  59  died 
only  indirectly  from  the  tumor,  perhaj^s  from  embol- 
ism, the  ergot  having  exi^elled  or  absorbed  the  tumor 
before  death.  In  cases  79  and  123  pregnancy  was  an 
important  factor  in  the  unfavorable  result."  Cases  93 
and  143  also  died.  Thus  of  the  153  cases,  140  remain 
cured  or  benefited. 

Prof.  W.  H.  Byford  reports  in  his  "Diseases  of 
Women"  101  cases,  including  27  of  Hilderbrant's,  9 
of  his  own,  14  of  White's  of  Buffalo,  and  the  remain- 
der from  a  score  of  physicians.  He  summarizes  them 
as  follows: 

"The  total  number  of  cases  here  cited  is  101 .  Twenty- 
two  of  them  are  reported  cured.  In  39  more  the 
tumors  were  diminished  in  size  and  the  hemoiThage 
and  other  disagreeable  symptoms  removed.  Nineteen 
of  the  remainder  were  benefited  by  the  relief  of  the 
hemorrhages  and  leucorrheal  discharges,  while  the 
size  and  other  conditi(ms  of  the  tumors  were  unchanged. 
Out  of  the  whole  number  only  21  cases  entirely  resisted 
the  treatment.  This  shows  results  decidedly  favor- 
able in  80  of  the  101  cases." 


LECTURE  V. 


ELECTRICITY. 


CURRENT. 

In  the  treatment  of  fibroids  of  the  uterus  by  elec- 
tricity the  direct  current,  or  what  is  more  commonly 
known  as  the  galvanic  current,  is  the  form  of  electricity 
almost  invariably  employed.  The  maximum  strength 
employed,  250  milliamperes  or  one-fourth  of  one 
ampere,  requires  an  aj)paratus  which  will  possess 
an  electro-motive  force  of  30  to  40  volts.  The 
amount  of  voltage  required  varies  in  different  cases 
wnh  the  varying  resistance  of  the  electrodes  and  the 
tissues  of  the  uterus  and  abdominal  wall  through 
which  the  current  must  act.  This  resistance  may  be 
from  60  to  300  ohms.  This  deviating  resistance  is 
accounted  for  by  the  use  of  different  kinds  of  elec- 
trodes and  the  variation  in  the  resistance  of  the  same 
tissues  in  different  individuals. 

APPARATUS. 

The  direct  current  may  be  generated  for  medical 
uses  from  a,  primary  batteries,  />,  from  dynamos  of  the 
non -alternating  or  non-interrupting  variety  employed 
for  incandescent  street  or  house  lighting  and  c,  stor- 
age or  secondary  batteries, 

PRIMARY    BATTERY. 

There  are  several  distinct  fcjrms  of  primary  cells 
emijloyed  by  gynecolcjgists  in  the  treatment  of  fibroids: 

Portahh  Battery. — The  old  reliable  pm-table  bat- 
tery is  the  one  with  zinc  and  carbon  elements  excited 


47 


by  a  fluid  of  sulphuric  acid  and  bichromate  of  potas- 
slum  in  water  in  cells  of  glass,  or  better,  hard  rubber. 
The  voltage  of  each  of  these  cells  when  freshly  charged 
is  about  2  volts.  Therefore  a  battery  of  this  descrip- 
tion of  about  18  cells  properly  connected  makes  a 
very  suitable  portable  battery  for  the  treatment  of 
fibroids. 

There  are  several  so-called  dry-cell  batteries  of 
secret  construction  which  appeal  to  one  on  superficial 
observation,  because  of  the  claims  of  their  inventors, 
of  cleanliness,  durability,  and  freedom  from  objec- 
tionable fluids.  All  such  batteries  should  be  looked 
upon  with  suspicion,  until  they  have  proved  them- 
selves capable  of  furnishing  an  electro-motive  force  of 
from  30  to  40  volts  for  periods  of  five  to  ten  minutes, 
several  times  a  day  for  several  months,  otherwise  the 
cost  of  recharging  makes  them  too  exiDensive. 

Office  Batteries. — For  office  battery  where  porta- 
bility is  not  required,  the  Law  cell,  the  improved  Le 
Clanche,  the  Diamond  Carbon,  or  cells  of  similar  con- 
struction should  be  employed.  They  should  be 
attached  to  a  selective  switchboard  of  such  a  construc- 
tion that  any  portion  of  the  battery  may  be  employed 
at  will.  These  cells  may  be  placed  in  an  adjoining 
closet,  or  cellar,  and  connected  with  the  switchboard 
by  a  cable  of  wire,  or  they  may  be  placed  in  a  cabinet 
beneath  the  switchboard.  As  these  cells  have  an 
average  voltage  of  one  or  one  and  a  quarter  volts  each, 
a  battery  of  about  40  cells  should  be  selected. 

Streei  Wire  Current. — One  of  the  most  satisfactory 
office  fixtures  for  electricity  is  a  connection  from  an 
incandescent  lighting  system  of  the  uninterrupted  or 
non-alternating  variety  reduced  by  some  safe  form  of 
rheostat.  One  of  the  simplest  rheostats  is  the  Mc- 
intosh (Fig.  1).  It  is  comi:)act,  easily  comi^rehended 
and  regulates  the  current  in  gradations  from  zero  to 
the  full  strength  of  the  street  current,  and  reverse, 
without  the  slightest  possibility  of  a  break.  A  fuse 
box  is  also  connected  with  this  rheostat  which  will 
bum  out  and  disconnect  the  current  from  the  patient 


48 


in  case  of  an  accidental  dangerous  increase  of  the  elec- 
tricity from  any  nnlooked  for  source. 

Storage  Ixitttn'ies  may  be  used  as  a  source  of  elec- 


tricity for  gynecologic  practice.  However,  as  they  are 
not  econ(jniical  and  wherever  they  can  be  used  to 
advantage  they  must  be  near  some  other  source  of  elec- 


49 


tricity,  it  is  obvious  that  one  would  seldom  select  this 
form  of  battery. 

MILLIAMPERE    METER. 

To  employ  galvanism  in  gynecologic  practice  with- 
out a  milliampere  meter  is  criminal.  There  are  three 
reasons  for  this:  1,  because  the  resistance  through  the 
abdominal  walls  is  so  small  and  variable,  that  no  one, 
no  matter  how  experienced,  can  even  approximately 
estimate  the  amperage  of  a  current  by  the  number  of 
cells  employed.  2,  because  of  the  powerful  current 
often  required  in  this  kind  of  work,  a  dangerous  dose 
might  easily  be  given,  and  3,  because  of  inaccuracy  in 
recording  cases. 


F Kit- RE   -2. 


A  milliampere  meter  should  be  selected  which  has 
two  readings :  One  scale  reading  to  500  milliamperes 
and  one  reading  to  50  milliamperes.  This  presup- 
poses in  reality  a  double  instrument.  By  changing  a 
switch  either  reading  may  be  selected  without  the 
necessity  of  changing  the  connections. 

The  best  milliampere  meter  I  am  acquainted  with 
is  the  Weston.  It  is  reliable,  convenient,  double 
reading,  dead  beat,  and  can  be  used  in  any  position  on 
a  level  without  regard  to  the  poles  of  the  earth.  The 
principal  objection  to  this  instrument  for  general  use 
is  its  expense  (Fig.  2). 


50 


An  instrument  which  I  have  employed  more  than 
any  other  in  my  work  outside  of  the  office  is  the  Mc- 
intosh instrument  (Fig.3).  It  is  of  the  galvanometer 
type  and  much  cheaper  than  the  Weston.  It  is  ap- 
proximately correct,  and  bamng  the  fact  that  it  must 
be  carefully  adjusted  to  the  polarity  of  the  earth,  be- 
fore each  using,  and  that  the  indicator  is  not  dead 
beat,  it  is  a  very  satisfactory  instrument.  It  has  a 
double  reading;  is  made  in  two  sizes,  one  large  for 
office  use  and  one  small  for  portable  purposes. 

ELECTRODES. 

In  describing  electrodes  for  use  in  the  treatment  of 


Figukp:  s. 


fibroid  tumors  I  will  limit  my  description  to  those 
which  I  actually  employ  in  my  own  work  and  leave 
the  innumerable  confusing  curiosities  which  adorn 
the  ordinary  instrument  catalogues  unmentioned. 

Ahdominal  electrodes  in  use  by  me  are  of  two  kinds 
according  to  the  dose  required.  When  a  current  of 
less  than  50  milliamperes  is  employed  a  large  si^onge, 
a  large  felt  (^r  a  large  spongio-pyoline  instrument  may 
be  emjjloyed.  These  electrodes  should  be  not  less 
than  six  })y  eight  inches  of  an  oval  shape.  They 
shoukl  be  thoroughly  washed  in  warm  water  before 
using,  and  all  surplus  water  squeezed  out  before  the 


51 


application  is  made.  For  a  current  above  50  milliam- 
peres  a  clay  electrode  or  the  author's  membranous 
abdominal  electrode  should  be  emx)loyed.  These 
being  the  only  instruments  which  I  have  found  in  my 
experience  which  will  uniformly  distribute  the  cuiTent 
and  prevent  burning  of  the  skin  in  spots. 

The  clay  electrode  is  the  cheapest  form  of  the  two. 
If  made  as  recommended  by  Goelet,  wrapped  in  cheese 
cloth  with  a  rubber  back  it  is  comparatively  clean  and 
makes  a  suitable  instrument  where  efficiency  and 
economy  alone  is  desirable.  It  is  constructed  of  jjot- 
ter's  clay  of  the  consistency  of  putty  molded  into  a 
cake,  about  eight  by  six  inches  in  diameter  by  one  inch 
in  thickness. 


Fiia-RE  4. 


The  membranous  abdominal  electrode  devised  by  the 
writer,  is  a  water  electrode,  the  cavity  of  the  disk  hold- 
ing the  water  being  covered  with  animal  membrane, 
the  membrane  furnishing  the  surface  of  contact  (Fig, 
4).  This  instrument  when  filled  with  warm  water 
makes  an  ideal  electrode.  It  is  cleanly,  its  temperature 
is  easily  regulated  and  it  diffuses  the  current  perfectly. 

For  internal  electrodes  I  employ  intrauterine,  vagi- 
nal and  rectal  instruments. 

The  intrauterine  electrodes  are  of  two  varieties; 
flexible  concentration  and  soft  copper. 

The  flexible  concentration  consists  of  platinum  wire 
wound  spirally  over  soft  copper  for  varying  distances 
tipped  with  hard  rubber,  and  the  portion  of  the  in- 


52 


strument  not  active,  is  covered  with  some  insulating 
material  as  rubber  or  linen  covered  with  shellac. 
These  instruments  may  be  made  of  any  diameter.  I 
have  them  in  sets  of  two,  three  and  five  millimeters  in 
diameter  respectively.  The  active  surface  which  I 
ordinarily  employ  is  four  square  centimeters  (Fig.  5). 
In  knowing  accurately  the  active  surface  of  an  elec- 
trode, one  can  estimate  more  definitely  the  particular 
effect  to  be  exj^ected  from  a  known  current.  This 
will  be  explained  more  comprehensively  when  we  con- 
sider treatment  technique. 

Soft  copi:)er  electrodes  are  employed  in  order  that 
the  uterine  mucous  membrane  and  deeper  tissues  may 
become  infiltrated  by  cataphoresis  with  the  salts  of 
copper  produced  by  a  combination  of  tissue  and  cop- 


o^ 


Figure  6. 

per  electrolysis,  which  occurs  at  the  positive  j^ole.  I 
have  these  electrodes  made  in  sets  of  three  instru- 
ments, each  instrument  having  an  electrode  of  diifer- 
ent  caliber  on  either  end  (Fig.  6).  This  makes  six 
diameters — 2,  4,  6,  8,  10  and  12  millimeters.  The 
length  of  each  electrode  surface  is  six  inches.  The 
portion  of  the  staff  not  employed  in  the  uterine  canal 
is  insulated  with  a  loose  rubber  muff. 

Vfujinal  electrode. — I  employ  an  instrument  for 
this  purpose  like  the  one  shown  in  Fig.  7.  It  has  an 
active  surface  of  alxjut  sixteen  square  centimeters,  the 
staff  of  it  being  insulated  with  hard  rubber  over  a 
copper  core.  The  instrument  is  about  six  inches 
long  and  about  three-quarters  (jf  an  inch  in  diameter. 

ReeUd  electrode. — I  employ  a  long  bulbous- 
pointed  instrument  about  four  inches  long  and  one- 


53 


half  inch  in  diameter  for  a  rectal  electrode.  The  insu- 
lated portion  has  a  metal  surface  of  about  ten  square 
centimeters.     The  staff  is  insulated  with  hard  rubber. 

Effects  of  Galvanism  on  Living  Tissues. — Fortu- 
nately the  effects  of  electricity  upon  living  tissues  has 
been  so  thoroughly  studied,  clinically  and  experi- 
mentally, in  the  last  few  years  that  we  are  in  a  posi- 
tion to  make  some  i^retty  definite  statements  about  its 
action.  These  studies,  too,  have  not  been  limited  to 
the  living  tissues,  but  have  been  carried  into  the 
chemic,  physiologic  and  bacteriologic  laboratories  to 
such  an  extent  that  we  have  many  experimental  proofs 
which  have  proved  true  several  former  theories  and 
exploded  many  others. 

In  applying  galvanism  to  the  tissues  of  the  body 
the  employment  of  two  electrodes  is  necessary.  In 
applying  electricity  to  fibroids  of  the  uterus  the  inter- 
nal electrode  is  usually  termed  the  active  pole  while 
the  external  one  is  called  the  passive  pole.  We  speak, 
therefore,  of  three  kinds  of  effects  from  the  applica- 
tion of  the  current  in  this  manner:  Polar  effects, 
inter-polar  effects  and  general  effects. 

The  polar  effects  differ  materially  with  the  pole 
employed.  In  several  respects  the  effects  at  the  two 
poles  are  diametrically  opposed. 

Effect  on  Sensihility. -The  positive  pole  or  anode  acts 
as  a  sedative  while  the  negative  or  cathode  pole  acts  as 
an  irritant.  This  effect  on  the  sensory  nerves  is  called 
the  electro-tonic  effect  and  the  two  effects  are  ex- 
pressed as  the  anelectro-tonic  effect  ( sedative )  and  the 
catelectro-tonic  effect  (irritant).  The  use  of  electricity 
in  gynecology  with  its  employment  of  large  doses  has 
abundantly  demonstrated  to  me  the  electro-tonic  effect 
of  galvanism. 

Effect  on  Blood  Vessels. — The  i^ositive  pole  con- 
tracts blood  vessels  in  its  immediate  neighborhood 
while  the  negative  pole  dilates  them.  These  vaso-con- 
strictor  and  vaso-dilator  effects  are  easily  demon- 
strated. 

Chemic  Reaction. — The  result  of  tissue  electrolysis 


54 


between  the  poles  produces  an  accumulation  of  alkalin 
elements  at  the  negative  pole  and  acid  elements  at  the 
positive  pole.  This  results  in  an  acid  reaction  ob- 
taining at  the  positive  pole  and  an  alkalin  reaction  at 
the  negative  pole.  If  the  electrolysis  is  persisted  in 
with  a  powerful  dose  these  polar  accumulations  become 
caustic  acids  and  caustic  alkalies  resiDectively. 

Effect  on  Tissue. — The  acid  accumulation  at  the 
positive  pole  when  it  becomes  sufficiently  concen- 
trated fi'om  the  effect  of  a  strong  dose  coagulates  the 
soft  tissues  and  renders  them  for  a  short  distance  from 
the  i3ole  hard  and  dry.  On  the  other  hand  the  alkalin 
accumulation  at  the  negative  pole  when  strongly  con- 
centrated by  a  strong  dose  of  electricity,  dissolves  the 
tissues  and  liquifies  in  the  same  manner  as  does  caustic 
alkalies. 

Effect  on  Pathogenic  Microbes. — A  zone  of  uterine 
tissue  around  the  positive  pole  of  a  depth  varying 
from  a  fraction  of  a  millimeter  to  one  or  two  millime- 
ters according  to  whether  the  dose  of  current  is  small 
or  great  is  rendered  bacteriologically  sterile  by  the 
employment  of  the  galvanic  current.  This  effect 
according  to  experiments  made  by  Gautier,  Apostoli, 
Enrico  Burci,  Vittorio  Frascani  and  others,  is  not  due 
to  the  electricity  direct  but  rather  to  the  chemic 
changes  occurring  around  the  positive  pole  as  the 
result  of  electrolysis.  For  instance,  if  a  copper  elec- 
trode is  employed  oxychlorid  of  copper  is  formed  as 
the  result  of  a  combination  between  the  electrolyzed 
tissues  and  copper.  This  chemic  combination  is  an 
active  germ  destroyer  and  in  solution  it  is  driven  by 
cataphoresis  into  the  tissues  to  a  considerable  distance, 
carrying  its  antiseptic  projjerties  with  it.  There  is 
scarcely  any  antiseptic  effect  at  the  negative  pole. 

INTERPOLAR     EFFECTS. 

While  it  is  easy  to  demonstrate  polar  action  it  is  not 
an  easy  matter  to  make  an  ocular  demonstration  of  the 
interpolar  effects  of  the  galvanic  current  on  living 
tissues. 


00 


From  exj)erience  in  the  emi^loyment  of  this  current 
on  living  healthy  and  ]3athologic  tissue,  experience  of 
many  earnest  investigators  extending  over  a  period 
now  of  several  years,  we  are  convinced  that  evidence 
enough  has  accumulated  to  justify  us  in  saying  that 
the  following  definite  effects  occur  in  tissues  so  acted 
upon:  1,  interpolar  electrolysis,  2,  stimulation  of 
trophic  nerves,  8,  cataphoric  action. 

Interpolar  Electrolijsis  undoubtedty  occurs  be- 
tween the  poles  as  well  as  at  the  metal  poles  them- 
selves. When  such  electrolysis  occurs  in  a  fibrcjid 
uterus  it  is  easy  to  account  for  the  reduction  in  size 
of  that  growth.  When  the  molecules  of  weaker  ten- 
acity in  such  tissues  become  decomposed  into  their 
constituent  elements  ozygen,  hydrogen,  carbon,  etc., 
these  elements,  as  gas  or  solid  i^articles,  immediately 
on  their  release  become  foreign  substances.  While 
seeking  for  new  combinations  some  of  them  are  taken 
into  some  of  the  many  absorbents  traversing  the  tis- 
sues and  are  carried  out  of  the  system.  Others  form 
new  combinations  with  free  elements  in  the  tissues,  or 
with  the  decomposed  material  of  the  electrodes,  or 
fluids  surrounding  the  electrodes  on  the  surface,  and 
still  others  are  liberated  at  the  poles  as  solids  or  gases. 

Stimulation  of  Trophic  Nerves. — While  the  elec- 
trolytic effect  of  the  current  may  account  for  reduc- 
tion or  absorption  of  growths,  I  believe  that  this  re- 
sult is  materially  hastened  by  powerful  stimulation  of 
the  trophic  apparatus  of  the  uterus  by  electricity.  We 
are  forced  to  believe  this  by  the  fact  that  the  general 
nutrition  and  functional  activity  of  all  the  organs,  any 
way  coming  under  the  influence  of  the  current,  are 
markedly  improved. 

The  Cataphoric  Action  of  the  Galvanic  Current. — 
This  is  the  property  of  a  current  of  electricity  which 
enables  it  to  push  or  conduct  fluids  in  bulk  through 
membranous  or  porous  conductors  in  the  direction  of 
the  current  flow,  from  the  positive  toward  the  nega- 
tive pole.  This  is  also  called  electrical  cataphoresis. 
Fluids  near  or  on  the  positive  pole,  either  simple  or 


56 

holding  in  solution  drugs  or  chemicals,  will  be  driven 
into  the  living  tissues  when  living  tissues  are  made  a 
portion  of  the  conductor.  So  that  the  tissues  of  the 
uterus  may  become  impregnated  with  any  drug  which 
can  be  dissolved  in  water  by  sun-ounding  an  intra- 
uterine iDOsitive  electrode  with  a  film  of  cotton  satu- 
rated with  the  particular  fluid  and  causing  a  current 
to  traverse  the  tissues. 

TJie  general  effect  of  galvanism  upon  the  tissues  is 
that  of  a  powerful  tonic.  Irregular  practitioners,  for 
a  large  number  of  years,  employed  electricity  in  some 
form  successfully  because  of  its  power  to  stimulate 
general  nutrition.  It  mattered  but  little  what  form  of 
electricity  was  employed,  or  where  it  was  applied  so 
long  as  some  portion  of  the  sick  man  became  a  part  of 
an  electric  circuit;  it  was  sure  to  stimulate  him,  im- 
prove his  nutrition  and  make  him  feel  a  stronger 
man.  The  powerful  doses  employed  in  the  use  of  gal- 
vanism in  the  treatment  of  fibroids  exaggerates  this 
tonic  effect  of  electricity  to  such  a  degree  that  many 
physicians  have  endeavored  to  attribute  to  it  all  the 
credit  for  improvement  of  fibroids  under  electricity. 

Summary  of  Effects  of  Galvanism  in  the  Treat- 
ment of  Fibroids  of  the  Uterus. 

Polar  Action:  Negative  Pole  a.  Irritant;  h.  Vaso- 
dilator; c.  Alkalin;  d.  Liquifies  tissues;  e.  Anti- 
septic (slight).  Positive  Pole  a.  Sedative;  b. 
Vaso-constrictor;  c.  Acid;  d.  Coagulates  tissues;  e. 
Antiseptic  (powerful). 

Interpolar  action:  Electrolysis  and  trophic  stimu- 
lation. 

General  Action:  Powerful  tonic. 

THE    APPLICATION    OF   GALVANISM   TO   THE   TREATMENT 

OF    FIBROIDS. 

What  is  the  present  status  of  the  treatment  of  these 
benign  tumors  by  electricity?  With  the  brilliant 
results  of  i)resent  surgery  as  a  competitor,  one  must 
have  considerable  courage  to  offer  electricity  as  a 
remedy  at  all  in  these  cases.     But  as  an  abdominal 


57 


surgeon  with  at  least  average  success,  and  at  the  same 
time  as  one  who  interested  himself  early  and  enthusi- 
astically in  the  much-lauded  Ajiostoli  treatment  when 
it  made  its  (Uhutin  this  country,  I  am  constrained  by 
sense  of  justice,  knowing  well  both  sides,  to  say  that 
in  the  interest  of  those  who  have  fibroids  of  the 
uterus,  that  the  knife,  even  in  these  times  of  brilliant 
successes  in  surgery,  is  used  too  often  and  electricity 
too  little.  If  a  brilliant  hysterectomy  with  its  aver- 
age mortality  of  5  per  cent,  ended  the  matter,  and  the 
95  per  cent,  recovering  gained  health  immediately,  we 
could  have  but  little  to  say.  When,  however,  we 
must  reckon  on  the  months  of  nervous  suffering  with 
which  the  majority  of  these  patients  who  have  their 
tumors  removed  have  to  contend,  after  this  operation, 
before  they  receive  the  well-earned  cure,  and  when  we 
take  into  consideration  the  not  large  but  certain  per- 
centage of  fistulas,  hernias  and  other  well-known  dis- 
tressing sequelae  following  oiDerations,  and  last  but  not 
least  when  we  remember  the  grim  specter  of  that  5  or 
10  per  cent,  who  did  not  recover,  are  we  not  justified  if 
we  have  a  conscience  (especially  when  we  realize  that 
a  fibroid  of  the  uterus  when  left  alone  seldom  proves 
fatal)  in  giving  our  patients  the  benefit  of  a  treat- 
ment, which  seldom  fails  to  relieve  these  cases,  and 
while  it  frequently  fails  to  cure,  never  kills  and  never 
does  harm  and  never  inferferes  ivifh  the  success  of 
an  operation,  if  it  in  the  end  fails  to  cure? 

Experience  in  the  treatment  of  fibroids  of  the 
uterus  by  electricity  has  taught  me  how  to  select  my 
cases,  when  to  encourage  a  patient  to  receive  elec- 
tricity and  when  to  encourage  her  to  select  an  opera- 
tion. Rules  which  I  have  formulated  and  allowed  to 
influence  me  but  not  control  me  (because  I  make 
frequent  exceptions  to  them  in  individual  cases)  are 
as  follows: 

WHEN   ELECTRICITY    IS   SPECIALLY  INDICATED. 

1.  In  bleeding  fibroids  in  women  approaching  the 
menox^ause. 


58 


2.  In  all  inoperable  cases. 

3.  In  incipient  fibroids  in  women  over  40  years 
of  age. 

4.  In  all  bleeding  fibroids  of  the  smooth  interstitial 
variety  which  have  no  symptoms  but  hemorrhage. 

5.  In  all  cases  (not  accompanied  with  pelvic  pus 
accumulation)  which  refuse  to  have  an  operation. 

TECHNIQUE  OF  TREATMENT  OF  TYPICAL  CASES. 

A  typical  case  for  the  successful  treatment  of 
fibroids  of  the  uterus  by  electricity  is  that  of  the  inter- 
stitial variety,  in  which  the  new  tissue  is  uniformly 
distributed  throughout  the  uterus,  enlarging  it  to  a 
symmetrical  tumor  of  varying  sizes,  and  proportion- 
ately expanding  the  uterine  canal.  These  cases  are 
almost  invariably  of  the  hemorrhagic  variety  because 
of  the  expansion  of  the  uterine  mucous  membrane. 
The  hemorrhage  occurs  as  an  exaggerated  menstrual 
flow.  These  tumors  vary  in  size  from  a  growth  the 
size  of  one's  fist  to  a  tumor  filling  the  abdomen  with 
a  uterine  canal  many  inches  deep.  Those  not  exceed- 
ing six  to  eight  inches  in  length  and  three  to  four 
inches  in  lateral  diameter  are  the  ones  in  which  elec- 
tricity accomplishes  the  best  results. 

METHOD   OF   PROCEDURE. 

We  seek  in  these  cases,  a,  to  transmit  through 
these  tumors,  for  its  electrolytic  effect,  as  strong  a 
current  of  galvanism  as  the  patient  will  bear,  without 
severe  discomfort,  and,  at  the  same  time,  not  to 
severely  cauterize  the  tissue  at  the  poles,  b,  We  seek 
to  get  acid  accumulation  at  the  positive  pole  located 
in  the  uterus,  of  sufficient  density  to  coagulate  the 
tissues  and  thus  lessen  the  bleeding  c,  This  same 
acid  at  the  positive  pole  we  expect  to  combine  with 
the  cojji^er  of  the  electrode  and  form  salts,  which  salts 
in  solution,  by  the  cataphoric  action  of  the  current 
will  be  driven  into  the  uterine  tissues,  immediately 
surrounding  the  electrode,  and  as  a  styptic  materially 
aid  in  curing  excessive  flow,     d,  We  seek  further  to 


59 

obtain  the  powerful  antiseptic  effect  as  the  result  of 
chemic  changes  occurring  around  the  internal  elec- 
trode, in  order  to  cure  the  endometritis  which  almost 
invariably  exists  as  a  painful  accompaniment  of 
fibroids. 

After  an  antiseptic  vaginal  douche  the  patient  to  be 
treated  is  placed  upon  a  table  on  her  back  with  her 
buttocks  drawn  well  to  the  edge  and  feet  supxDorted  by 
stirrups.  The  size,  shape  and  direction  of  the  uterine 
canal  is  obtained  by  the  use  of  large,  flexible  sounds. 
A  large  copper  electrode,  then,  of  suitable  diameter,  is 
properly  shaped  and  passed  to  the  bottom  of  the 
uterine  canal,  and  the  vaginal  portion  insulated  with 
the'rubber  muff.  This  electrode  is  then  attached  to  the 
positive  terminal  of  the  battery.  A  clay,  or  the  writer's 
membranous  abdominal  electrode,  is  next  passed  under 
the  loose  clothing  and  placed  on  the  abdomen  and 
then  attached  to  the  negative  pole  of  the  battery. 

The  current  is  now  gradually  turned  on  while  the 
milliampere  meter  is  carefully  watched  and  the  fea- 
tures of  the  patient  are  closely  scanned  for  signs  of 
pain,  until  the  current  reaches  100  to  150  or  even  200 
milliamiDeres,  according  to  the  tolerance  of  the 
patient  and  the  size  of  the  active  internal  electrode. 
If  the  active  electrode  is  of  the  ordinary  diameter  of 
from  3  to  5  millimeters,  a  current  strength  of  100 
milliamperes  can  be  used  safely  in  any  particular 
case  for  every  two  inches  in  length  of  this  electrode 
which  is  active.  To  he  more  accurate,  the  current 
should  not  exceed  in  strength  25  milliamperes  for  each 
square  centimeter  of  active  surface  of  the  internal 
electrode. 

So  that  in  the  general  run  of  cases  one  can  safely 
give  the  patient  as  strong  a  current  as  she  will  bear 
without  danger  of  producing  excessive  cauterization 
at  the  active  pole.  This  will  vary  from  100  to  200 
milliamperes.  The  time  of  each  treatment  should  be 
five  minutes  for  the  maximum  current  employed. 
The  treatment  should  be  given  as  often  as  every  sec- 
ond day.     Except  in  cases  of  continuous  flowing,  the 


60 


treatments  are  best  given  between  the  menstrual 
periods. 

These  cases  begin  to  improve  almost  immediately. 
The  lirst  improvement  is  in  relief  of  neuralgic  and 
so-called  pressure  pain.  In  a  few  days  they  find  that 
their  general  strength  is  improved.  Reflex  disturb- 
ances such  as  stomach  irritation,  palpitation  of  the 
heart,  occipital  headache  and  backache  will  be  re- 
lieved. The  patient  will  begin  to  eat  and  sleep  nat- 
urally. There  is  a  general  feeling  of  well  being 
engendered.  In  a  few  days  the  leucorrhea  or  puru- 
ent  discharge  from  the  endometrium  will  diminish. 
As  the  patient  arrives  near  the  menstrual  period,  she 
finds  that  the  old  premenstrual  aches  are  not  present, 
the  old  despondency  is  absent.  If  the  treatment  has 
been  sufficiently  active  the  menstrual  flow  will  arrive 
without  iDain  frequently.  Occasionally,  the  first 
month,  the  flowing  is  fully  as  free  as  usual,  although 
frequently  it  is  much  less.  If  the  treatment  is  con- 
tinued for  two  or  three  months  these  patients  will 
begin  to  maintain  that  they  feel  perfectly  well. 
All  the  old  distressing  symptoms  will  very  often  dis- 
appear entirely,  they  will  gain  flesh  and  the  uterine 
discharge  will  become  normal.  While  the  tumor  will 
still  be  apparent  to  the  physician's  examination  it 
will  almost  invariably  be  found  to  be  much  dimin- 
ished in  size.  When  the  time  arrives  in  the  treatment 
that  these  patients  are  symx^tomatically  cured,  that 
is  when  they  feel  no  symiotoms,  I  usually  discharge 
them.  I  always  inform  them  that  the  tumor  has  not 
disappeared,  and  that  sometime  it  may  again  give 
them  the  old  difficulties.  As  long  as  they  are  free 
from  these  they  may  be  satisfied  that  the  tumor 
is  not  growing — on  the  contrary  decreasing  in  size. 
However,  if  the  old  symj)toms  begin  to  return  I 
instruct  them  to  seek  relief  again  in  the  electricity. 

The  above  treatment  applies  to  the  typical  bleeding 
fibroids  of  interstitial  variety. 

Where  the  uterus  is  large  and  the  canal  is  deep,  it 
is  necessary  sometimes  to   attack  the  mucous  mem- 


61 

brane  by  piecemeal,  in  order  to  get  sufficient  concen- 
tration with  the  dose  tolerated  to  accomplish  sufficient 
changes  in  "the  endometrium  to  check  hemorrhage. 
The  concentration  necessary  should  approximate  25 
milliamperes  for  each  square  centimeter  of  the  elec- 
trode in  contact  with  the  mucous  membrane.  For 
examiDle,  if  a  patient  will  only  bear  a  current  of  100 
milliamxDeres,  one  should  select  an  electrode  of  copper 
or  zinc  or  platinum  with  a  diameter  of  proper  dimen- 
sions, insulated  to  all  but  4  square  centimeters  of  its 
distal  end.  The  depth  of  the  canal  is  measured.  Then 
commencing  with  the  distal  end  of  the  cavity,  the 
exposed  active  surface  of  the  electrode  is  made  to 
cover  in  successive  treatments  its  whole  surface.  By 
doing  this  the  whole  mucous  membrane  is  acted  uj^on 
uniforndy  without  employing  at  any  time  a  larger 
dose  than  100  milliamperes. 

INOPERABLE  AND  COMPLICATED  CASES. 

The  cases  which  are  referred  to  the  writer  for  elec- 
trical treatment,  in  these  days  when  active  surgery 
offers  such  a  large  percentage  of  recoveries  from  hys- 
terectomies^ are  for  the  most  part  complicated  cases, 
which  the  ordinary  surgeon  shuns. 

One  complication  which  frequently  induces  the  sur- 
geon to  shift  the  responsibility  of  these  cases,  is  that 
of  severe  purulent  metritis  and  endometritis,  accom- 
I^anied  frequently  with  discharges  of  gangrenous 
masses  from  submucous  fibroids,  all  accompanied  with 
much  pain,  more  or  less  hemorrhage,  and  with  the 
discharges  inclined  to  be  very  offensive.  The  patients 
are  usually  poorly  nourished,  with  white  and  waxy 
skin  in  consequence  of  septic  absorptions.  When 
they  reach  this  stage  they  are  frequently  pronounced 
malignant.  The  outlook  for  an  operation  certainly  is 
not  flattering. 

Now  the  writer  has  been  honored  frequently  by 
having  such  cases  sent  to  him  for  electrical  treatment, 
by  different  friends  of  his  who  are  conscientious  sur- 
geons. 


62 


What  have  we  to  deal  with?  Usually  a  tumor  of 
large  size  extending  to  the  navel.  It  is  soft,  with 
nodular  masses  projecting  from  its  peritoneal  surfaces. 
The  cervix  is  soft  and  patulous,  with  a  canal  large  and 
irregular.  Sometimes  a  small  nodular  mass  is  pre- 
senting at  the  cervix,  This  is  usually  soft  and  easily 
broken  down.  The  endometrium  and  all  cavities  from 
which  masses  have  been  projected  or  from  which 
masses  have  sloughed  away  are  infected  and  ulcerat- 
ing, and  emitting  a  discharge  which  rapidly  becomes 
offensive.  From  the  large  mucous  membrane  periodic 
and  irregular  uterine  discharges  are  occurring,  serving 
to  swell  the  already  copious  outpour. 

The  writer  has  treated  by  electricity  and  symptom- 
atically  cured  several  of  these  cases  in  which  a  diag- 
nosis of  cancer  had  been  made  by  men  of  more  than 
ordinary  talent. 

I  prefer,  when  it  is  practicable,  to  dilate  the  canals 
carefully  in  these  cases,  and  remove  with  a  dull  curette 
the  sui3erficial  debris  before  beginning  the  electricity. 

I  then  select  one  of  the  largest  copper  electrodes 
which  can  be  inserted  and  make  it  the  active  positive 
pole,  inserting  it  to  the  bottom  of  the  canal  with  its 
whole  surface  uninsulated.'  With  the  abdominal  elec- 
trode in  place,  a  current  is  gradually  turned  on  until 
a  strength  of  200  milliamperes  is  reached,  or  the  max- 
imum amount  under  that  strength  that  the  patient 
will  tolerate. 

These  treatments  should  be  given  every  other  day. 
Antiseptic  douches  should  be  employed  night  and 
morning. 

These  cases  respond  rapidly.  The  powerful  anti- 
seijtic  action  on  the  mucous  membrane  makes  itself 
apparent  by  the  decreased  odor  of  the  discharge.  The 
passing  and  withdrawing  of  the  electrode  opens  and 
provides  free  drainage  for  the  secretions.  The  tissues 
become  tanned  by  the  salts  of  copper  which  are  forced 
into  them  by  catai)horesis,  and  the  discharge  of  blood 
is  lessened.  The  patient  is  toned  by  the  general  efPect 
of  electricity  on  her  system.     In  a  word,  it   is   fre- 


63 


quently  marvelous  what  a  transformation  will  take 
place  in  these  apjmrently  hopeless  cases  in  a  few 
weeks  of  judicious  galvanic  treatment. 

While  these  cases  are  apparently  hopeless,  often- 
times when  they  are  "given  over'  by  the  surgeon, 
they  are  frequently  symi)tomatically  cured  by  this 
simple  remedy.  The  writer  has  a  long  list  of  such 
cases,  and  they  constitute  some  of  the  most  satisfac- 
tory work  he  has  ever  had  placed  to  his  credit. 

INOPERABLE  TUMORS  TREATED  BY  OTHER  THAN  THE 
INTRAUTERINE  METHOD. 

There  is  a  class  of  comi^licated  cases  of  difiPerent 
kinds  in  which  it  is  impossible,  because  of  the  contor- 
tions of  the  growth,  to  enter  the  uterine  canal  with 
an  electrode.  Occasionally  the  tumor  has  displaced 
the  cervix  so  that  it  is  drawn  high  in  the  vagina  above 
the  bladder,  out  of  reach  of  finger  or  sound;  while 
again  it  is  drawn  up  posteriorly  with  the  uterine  canal 
forming  an  acute  angle  with  the  vagina.  In  all  cases 
where  it  is  imjoossible  to  reach  the  canal,  if  they  are 
treated  by  electricity,  it  is  necessary  to  employ  it 
without  the  advantages  of  an  intrauterine  electrode. 

Only  in  the  most  desperate  cases,  in  which  submit- 
ting to  an  operation  is  clearly  suicidal,  would  one 
think  of  employing  electricity  as  a  means  of  treat- 
ment, when  an  intrauterine  electrode  was  impossible. 
But  it  is  in  just  these  cases,  with  their  distressing 
neuralgic  and  pressure  symptoms,  with  dyspeptic  com- 
plainings and  bowel  irritations,  the  result  of  reflex 
nerve  disturbances,  in  which  an  operation  is  discour- 
aged, that  we  find  patients  ready  to  catch  at  any  straw. 

In  many  of  these  cases  I  believe  that  electricity  not 
only  offers  a  straw,  but  a  veritable  lifeboat  to  their 
despairing  bodies. 

When  an  intrauterine  electrode  is  not  practicable, 
then  we  should  employ  some  other  form  of  internal 
electrode  which  will  have  the  effect  of  causing  the 
current  of  galvanism  to  pass  directly  through  the 
largest  portion  of  the  tumor. 


64 


If  the  vagina  is  not  distorted  so  but  that  a  vaginal 
electrode  may  be  employed,  that  instrument  should  be 
used  (Fig.  7),  placing  its  active  point  posterior  to 
the  tumor.  This  should  be  made  tiie  negative  pole. 
The  abdominal  electrode  should  be  placed  in  such  a 
position  that  the  largest  diameter  of  the  tumor  is 
interposed  between  it  aiid  the  vaginal  electrode.  A 
current  of  50  to  100  milliamjjeres  may  be  safely  em- 
ployed, if  tolerated,  for  a  period  of  five  minutes.  The 
treatments  may  be  given  as  often  as  every  second  day, 
and  in  a  few  cases  every  day  where  it  is  well  borne. 

When  a  vaginal  electrode  can  not  be  employed  to 
advantage  in  these  cases,  a  rectal  electrode  (Fig.  8) 
should  be  employed.  This  should  be  placed  well  up 
opposite  the  tumor.     It  should  be   employed  as  the 


Figure  7. 


Figure  8. 

negative  pole.  It  should  have  an  active  surface  of 
more  than  eight  centimeters  and  the  current  should 
never  exceed  200  milliamperes. 

All  we  can  expect  to  accomplish  in  this  treatment 
is  that  beneficial  action  derived  from  passing  a  strong 
direct  current  through  any  tissue  containing  muscles, 
nerves,  lymphatics  and  blood  vessels,  viz.,  a  powerful 
trophic  stimulation  to  the  part,  and  incidentally  a 
powerful  general  tonic  effect  on  the  general  system. 

These  cases  get  great  relief.  Neuralgias  stop. 
Troublesome  abdominal  reflexes  cease.  Circulation 
is  improved.  Nutrition  is  stimulated.  Sleei)lessness 
disappears.  Bowels  are  stimulated  and  relieved  of 
troublesome  distension  symptoms.  The  tumors  often 
seem  to  decrease  in  size.     The  degree  to  which  each 


65 


of  these  symptoms  are  relieved  varies,  of  course,  much 
in  individual  cases.  The  writer  has  seen  a  large  num- 
ber  of  cases  completely  and  for  an  indefinite  time, 
relieved  of  all  these  symptoms.  In  fact,  some  of  the 
most  gratifying  cases  of  relief  he  has,  are  of  this 
variety„  Their  cases  are  apparently  so  hopeless  that 
often  any  relief  is  very  gratifying. 


LECTUKE  VI. 


SURGICAL  environments:  operating  room;  steril- 
izers;  STERILIZING  INSTRUMENTS,  LIGATURES  AND 
hands;  CATGUT  PREPARATIONS;  PREPARATORY 
AND   AFTER   TREATMENT  OP   PATIENTS. 
DRAINAGE. 


The  environments  of  a  patient  who  is  about  to  submit 
to  a  surgical  oiDeration  for  a  fibroid  of  the  uterus  must 
be  made  surgically  clean..  These  environments  include 
operating  room,  bed,  sterilizers,  instruments,  ligatures 
and  operators'  and  assistants'  hands  and  clothing. 

OPERATING    ROOM. 

In  a  imvate  house  a  room  should  be  selected  which 
has  direct  light  through  one  or  two  large  windows;  a 
room  which  can  be  stripped  of  furniture,  hangings 
and  carpets.  It  should  be  convenient  to  the  bedroom 
of  the  patient,  or  better  the  bed  can  be  placed  in  the 
room  in  readiness  for  use  when  the  o^oeration  is  fin- 
ished— the  operating  room  constituting  the  bedroom. 
The  woodwork  of  this  room  should  be  thoroughly 
scrubbed  with  soap  and  water,  and  the  walls  and  ceil- 
ing carefully  wiped  free  of  dust.  The  room  should 
be  thoroughly  aired  by  opening  the  windows  and  a 
reliable  means  of  heating  should  be  at  hand  in  order 
to  render  it  dry  and  to  keep  it  at  a  temperature  of 
80  degrees  F.  when  required.  The  table,  which  is 
selected  for  the  operating  table,  and  the  stands  for 
instruments  and  dressings,  together  with  all  recep- 
tacles or  slop  tubs  and  basins  should  be  carefully 
scrublx^d  and  then  conscientiously  wiped  with  a  1:500 
solution  of  chlorid  of  mc^rcury.  All  tin,  iron  or  i3orce. 
lain  basins  should  be  boilM  for  one-half  hour  in  a  wash 


67 

boiler  or  other  large  boiler,  as  a  means  of  sterilization 
Tho  bed,  if  possible,  should  consist  of  a  hair  mat- 
tress which  has  recently  been  purified  by  steam.  In 
a  hospital  a  largo  steam  sterilizer  should  be  jirovided 
where  hair  mattresses  can  be  sterilized  frequently. 
The  bed  should  be  comjjleted  with  dry  sterilized 
sheets,  blankets  and  pillow  slips.  If  there  is  no 
sterilizer  at  hand  the  bedding  can  be  sterilized  by 
boiling  in  water  one-half  hour,  and  drying  in  a  pure 
room,  and  ironing  with  a  hot  iron  by  an  intelligent 
attendant  or  nurse.  Growns,  towels  and  aprons  should 
be  sterilized  in  the  same  manner  as  the  bedding,  pro- 
vided  there  is  no  regular  steam  sterilizer  at  hand. 

In  an  institution  the  operating  room  should  have 
floor  and  walls  of  such  material  that  they  can  be  thor- 
oughly washed  with  antiseptic  solutions  and  jjrovided 
with  a  central  drain  which  will  allow  the  cleaning  of 
the  walls  and  floors  with  water  direct  from  a  hydrant 
through  a  hose.  The  drain  should  be  reliably  trapped, 
or  better,  drain  directly  in  to  the  external  air.  For 
convenience,  a  perfectly  fitted  oj^erating  room  should 
have  several  anterooms,  including  a  preparatory  room 
where  the  solutions  are  prepared,  the  water  sterilized, 
and  where  the  heating  apparatus  for  the  sterilizers 
and  the  sterilizers  themselves  are  located.  This  room 
should  have  washable  walls.  There  should  also  be 
one  or  more  anesthetizing  rooms,  and  finally  there 
should  be  convenient  dressing  and  wash  rooms  for 
the  surgeon  and  his  assistants.  The  private  operating 
room  which  I  use  at  the  Woman's  Hospital  is  shown 
in  Fig.  9.  It  has  direct  side  light  and  a  large  skylight. 
Its  walls  and  floors  are  of  marble.  It  is  lighted  at  night 
entirely  by  incandescent  electric  lights,  gas  being 
impracticable  where  an  anesthetic  is  necessary;  these 
lights  are  in  abundance,  so  that  an  operation  can  be 
performed  equally  well  at  night  or  day.  The  prepar- 
atory room  is  adjacent.  This  is  shown  in  Fig.  10. 
It  is  entirely  in  marble.  The  battery  of  Boeckmann's 
sterilizers  is  shown  in  the  foreground.  In  the  far- 
ther end  are  two  large  tanks  in  which  the  water  is 


68 

sterilized  for  the  operation,  one  being  filled  with  cold 
sterilized  Avater  and  the  other  with  hot  water.  They 
are  connected  with  the  operating  room  by  large  fau- 
cets which  pass  through  the  wall.  Directly  otf  from 
this  room  is  an  anesthetizing  room,  and  adjacent  to 
this  are  two  dressing  rooms  with  washing  utensils. 
In  the  oj)erating  room  is  a  spectators'  rail  which  sep- 
arates the  ojDerator,  assistants,  nurses  and  all  operat- 
ing paraphernalia  from  those  who  may  be  invited  to 
vritness  operations. 

Sterilizers. — In  a  private  house,  in  emergency  cases, 
an  ordinary  copper  or  tin  wash  boiler  may  take  the 
place  of  the  most  elaborate  sterilizer.  The  gowns, 
towels,  gauze  operating  sheets  and  all  large  articles 
used  externally  can  be  thoroughly  sterilized  by  boil- 
ing for  thirty  minutes.  For  sterilizing  instruments, 
silkworm  gut,  silk  and  other  smaller  articles  a  smaller 
kitchen  article  such  as  a  sauce  pan,  or  porcelain- 
lined  flat  pan,  may  be  utilized  as  a  sterilizer. 

In  large  institutions  large  steam  sterilizers  are  em- 
ployed. I  have  used  the  Arnold  sterilizer  for  dress- 
ings and  instruments  and  other  small  articles  until 
quite  recently,  since  which  time  I  have  adopted  for 
my  hospital  work  the  Boeckmann  steam  sterilizer  (Fig. 
11).  These  sterilizers  are  simple  in  construction,  dur- 
able, inexpensive,  efficient  for  all  work,  even  the  steril- 
ization of  catgut,  and  they  possess  the  advantage  of 
sterilizing  with  steam,  while  at  the  same  time  when  the 
process  is  finished  the  articles  are  left  perfectly  dry. 

At  the  Woman's  Hospital  several  of  these  sterilizers 
are  employed  and  everything  that  is  liable  to  be 
required  in  several  operations  is  sterilized,  and  the 
unopened  sterilizers  are  placed  in  the  operating  room 
for  future  use.  Surgeon's  and  nurses'  gowns,  towels, 
gauze,  silk  and  silkworm  gut  in  cotton -stoppered  test 
tuVjes  are  removed  as  they  are  required  at  the  time 
oi  the  operation,  while  a  separate  hot  water  sterilizer 
(Fig.  12)  is  employed  immediately  before  the  opera- 
tion  for  steriliziug  iho  instruments. 

Lif/atures.—l  employ  braided  silk,  silkworm  gut 


71 


and  catgut  for  sutures  and  ligatures.  Silk  and  silk> 
worm  gut  I  sterilize  by  boiling,  or  by  steam  in  the 
Boeckmann  sterilizer.  They  are  placed  in  small  skeins 
in  large  test  tubes  loosely  stoppered  with  cotton  and 
subjected  to  a  temperature  of  boiling  water  for  twenty 
minutes  on  two  successive  days  when  t  have  no  sterilizer 
at  hand,  and  to  the  temperature  of  the  superheated 
steam  for  a  like  length  of  time  in  my  hospital  work.  I 
only  open  at  the  operation  a  sufficient  number  of  tubes 


^^ 


Figure  11. 


for  the  operation  in  hand,  the  balance  being  reserved 
for  future  cases.  Tubes  of  silk  and  silkworm  gut  may 
be  prepared  in  considerable  numbers  and  sterilized  by 
steam  with  an  efficient  cotton  filter  and  afterward  car- 
ried to  operations  anywhere.  On  opening,  the  cotton 
stopper  is  first  burned  down  low  with  the  tube,  then 
removed  and  the  skein  of  material  carefully  lifted  out 


72 


with  sterilized  forceps  and  placed  in  sterilized  water 
when  it  is  ready  for  use. 

Cat  gut  is  the  form  of  absorbable  ligature  which  I, 
employ  for  buried  sutures.  I  have  it  sterilized  in  the 
Boeckmann  sterilizer  with  dry  heat  at  a  temperature 
of  284  degrees  F.  for  a  period  of  three  hours.  Previ- 
ous to  sterilization,  the  catgut,  cut  in  suitable  lengths, 
is  wrapped  in  oiled  paper,  one  thread  in  each  paper 
and  the  paper  enclosed  in  small  hermetically  sealed 
envelopes.  While  this  accomplishes  perfect  steriliza- 
tion, as  can  be  demonstrated  by  bacteriologic  tests  it 
has  been  argued  that  sterilized  catgut  may  act  as  a 
very  favorable  nidus  for  the  growth  of  pathogenic 
germs  in  tissues  in  which  it  is  buried,  tissues  which 


Figure  12.— Boeckmann*s   Instrument  Sterilizer. 

without  the  presence  of  this  i)erfect  sterilized  culture 
medium  would  be  competent  to  resist  the  few  germs 
left  in  a  wound,  after  ordinary  surgical  precautions 
had  been  exerted.  For  this  reason  I  not  only  render 
my  catgut  aseptic  with  heat  but  I  sui)plement  that 
process  by  saturating  it  with  non-poisrmous  antisep- 
tics. According  to  Arthur  Wocxlward  Booth's  admir- 
able article  in  the  TJirrdpculir  (Jfrzcffr,  December, 
1894,  he  found  that  pyoctanin  blue  in  a  1  to  1000 
alcoholic  solution  will  render  catgut  thoroughly  anti- 
septic and  at  the  same  time  imjjart  to  it  a  longer  life. 
Pyoct?inin  is  a  much  more  i)owerful  antise])tic  than 
chromic  acid  and  therefore  may  be  employed  in  more 


73 


diluted  form.  Compared  with  bichlorid  of  mercury  it 
is  a  more  perfect  germicide,  non-poisonous,  and  it  im- 
parts a  longer  life  to  the  gut.  Catgut  saturated  with 
pyoktanin  becomes  an  antiseptic  suture,  the  antiseptic 
of  which  can  in  no  way  prove  a  source  of  danger. 

THE  writer's    method  OF  CATGUT  PREPARATIONS. 

A  skein  of  new  catgut  is  cut  into  about  four  lengths. 
This  makes  the  threads  of  about  forty  inches  each. 
Each  section  of  the  skein  is  twisted  into  a  loose  knot 
and  they  are  soaked  in  ether  for  twenty-four  hours  in 
order  to  remove  the  fat.  It  is  then  boiled  in  alcohol, 
in  a  closed  jar,  for  one  hour  in  the  steam  sterilizer. 
Before  boiling  in  alcohol  the  bunches  are  divided  into 
their  separate  threads  and  each  thread  twisted  into  a 
little  coil.  After  the  sterilization  by  alcohol  it  is  care- 
fully removed  from  the  jar  by  an  intelligent  conscien- 
tious nurse,  with  sterilized  forceps  in  sterilized  hands, 
to  a  jar  containing  a  solution  of  pyoctanin  1  to  1000 
in  absolute  alcohol.  Here  it  is  allowed  to  remain  for 
twenty-four  hours  in  order  to  become  thoroughly  sat- 
urated with  that  powerful  antiseptic.  I  then  have  it 
distributed  into  small  wide-mouthed  one-half  ounce 
bottles,  containing  oil  of  juniper.  Into  each  of  these 
bottles  about  four  of  the  forty-inch  strands  are  placed. 
The  bottle  is  then  corked  with  a  rubber  stopi^er  and 
is  not  opened  until  it  is  to  be  used  at  an  operation, 
when  the  catgut  is  threaded  directly  from  the  bottle. 
The  bottle,  or  several  bottles,  with  their  rubbsr  stop- 
pers may  be  immersed  in  a  1  to  1000  bichlorid  solution 
on  the  instrument  table  ready  to  be  opened  by  the  sur- 
gical nurse  in  the  course  of  the  operation.  After  it 
has  once  been  opened  I  discard  any  small  amount  of 
catgut  which  may  remain  after  the  operation,  prefer- 
ring to  use  always  from  a  fresh  supply. 

Instead  of  boiling  the  catgut  in  alcohol  it  may  be 
sterilized  in  closed  enveloi^es  in  the  Boeckmann  ster- 
ilizer as  before  described,  at  a  temperature  of  284 
degrees  F.,  and  then  treated  from  that  point  in  the 
same  way  as  that  sterilized  by  boiling  in  alcohol. 


74 

It  seems  to  me  that  this  is  an  ideal  and  simple 
method  of  catgut  preparation.  There  can  be  no  doubt 
of  its  absolute  sterilization  after  it  has  been  boiled  in 
alcohol  for  two  hours,  or  after  it  has  been  submitted 
for  three  hours  to  a  temperature  of  284  degrees  F.  in 
the  sealed  enveloi^es  in  the  Boeckmann  sterilizer. 

Dr.  Booth  found  that  pyoktanin  permeated  every 
fiber  of  catgut  when  it  had  lain  in  a  1  to  1000  alcoholic 
solution  of  the  drug  for  twenty-four  hours. 

Dr.  Booth  quotes  Sternberg  as  quoting  Jaenicke  on 
the  antiseptic  properties  of  pyoctanin  as  follows: 

Staphylococcus  pyogenes  aureus  restrained  by  solu- 
tion of  1  to  2,000,000;  bacillus  anthrax  aureus  re- 
strained by  solution  of  1  to  1,000,000;  streptococcus 
pyogenes  aureus  restrained  by  solution  of  1  to  333,000. 
In  blood  serum  stronger  solutions  are  required. 

Thus  we  have  not  only  a  sterile  catgut,  but  we  have 
that  sterile  catgut  thoroughly  saturated  with  an  effi- 
cient and  non-poisonous  antiseptic.  The  juniper  oil 
preserves  the  catgut  indefinitely,  it  fixes  the  pyctanin 
so  that  it  will  not  stain  the  hands,  and  it  keeps  the 
catgut  soft  and  pliable. 

The  life  of  the  catgut  in  the  tissues  prepared  by  this 
method  is  a  little  less  than  that  prepared  by  chromic 
acid,  but  considerably  longer  than  that  prepared  by 
bichlorid  of  mercury.  By  placing  it  in  small  bottles 
it  can  be  handled  economically  without  the  necessity 
of  ever  being  obliged  to  open  twice  the  same  supply. 

Spomjes. — Sea  sponges  are  not  safe  when  prepared 
under  the  most  careful  supervision,  whereas  gauze 
sponges  may  be  perfectly  reliable  whenever  there  is 
the  simplest  device  at  hand  in  which  they  may  be 
boiled. 

The  best  gauze  sponges  are  made  from  loose-mesh 
gauze  folded  into  three  or  four  thicknesses,  with  the 
edges  fastened  with  a  running  stitch  of  cotton  thread. 
They  may  be  made  of  any  size.  These  sponges  are 
sterilized  in  a  steam  sterilizer,  or  in  emergency  cases 
they  may  be  sterilized  by  })oiling  with  the  instruments. 
In  laparotomy  cases  I  prefer  those  sterilized  by  the 


76 


dry  metliod.  They  are  then  used  but  orice  and  are 
discarded.  This  is  not  economical  because  of  the 
large  number  of  sponges  frequently  required,  nor  is  it 
necessary.  The  advantage  possessed  by  the  dry  sponge 
is  in  the  increased  absorptive  power  of  the  gauze. 

Gauze. — The  writer  has  devised  an  apparatus  in 
which  to  sterilize  gauze  for  operations,  either  for  hos- 
pital operations  or  o^^erations  away  from  home.  Chas. 
Truax,  Greene  &  Co.  kindly  constructed  this  apparatus 
for  me,  as  well  as  the  furniture  shown  in  the  operating 
room  in  Fig.  9.  It  consists  of  a  little  stand  which  fits 
into  the  catgut  sterilizer  of  the  Boeckmann  ajDparatus, 
or  which  can  be  set  into  any  steam  sterilizer  (Fig.  13). 


Figure  13. 


Figure  14. 


The  stand  contains  seven  large  test  tubes,  two  inches 
in  dicimeter,  and  about  eight  inches  in  length.  In 
each  of  these  tubes  can  be  placed  all  the  gauze  of  any 
one  kind  that  will  be  required  at  any  ordinary  oi)era- 
tion,  which  is  about  two  yards  of  sheet  iodoform  gauze. 
Ordinarily  I  have  two  tubes  filled  with  iodoform  sheet 
gauz(^,  one  with  j^lain  sterilized  gauze,  one  with  one- 
inch  strip  i(jdoform  gauze  cut  the  strong  way  of  the 
cloth,  one  with  two-inch  strij)  iodoform  gauze  cut  in 
the  same  way,  and  one  with  a  skein  of  silkworm  gut 
and  a  skein  i)i  braided  silk.  These  tubes  are  loosely 
filled  and  tlieir  mouths  closed  with  cotton.  They  are 
then  Bu})jected  U)  steam  sterilization   in  the  Boeck- 


78 

mann  or  other  steam  sterilizer  at  maximum  heat  for 
one  hour.  They  are  then  set  aside  and  the  following 
day  they  are  again  subjected  to  the  superheated  steam 
for  one  hour,  and  then  dried  by  removing  the  cork  in 
the  top  of  the  Boeckmann  sterilizer  so  as  to  get  the 
action  of  the  diy  heat.  The  contents  of  the  tube  are 
now  thoroughly  and  permanently  sterilized,  and  will 
remain  so  for  weeks  if  the  cotton  stoppers  in  the 
mouth  of  the  tubes  are  not  removed. 

When  I  wish  to  preserve  these  tubes  for  indefinite 
use  I  have  the  nurse  slip  a  sterilized  rubber  cap  over 
the  cotton  and  the  end  of  the  tube  before  removing 
them  from  the  sterilizer.  They  may  then  be  set  aside 
for  an  indefinite  time. 

When  I  wish  to  operate  away  from  the  hospital,  I 
place  the  rack  containing  the  tubes  required  into  a 
metal  box  (Fig.  14),  and  that  in  turn  is  stored  away  in 
my  instrument  bag. 

Preparation  of  Operator  and  Assistants.  —  It 
should  not  only  be  taken  for  granted  but  should  be 
insisted  on,  that  any  and  all  persons  participating  in 
the  high  calling  of  surgery  should  take  a  general  bath, 
including  the  hair,  every  day. 

Dress. — For  important  operating,  such  as  we  have 
to  deal  with,  special  dress  for  the  oj)erator  and  assist- 
ants is  indispensable.  Suits  of  white  ducking  or 
linen  should  displace  the  street  apparel.  Over  this 
sterilized  gowns  should  be  worn.  In  this  dress  the 
operator  can  be  comfortable  and  do  hard  work  in  a 
temperature  of  80  degrees  F.  When  he  is  through 
oi^erating  all  wet  clothing,  made  so  by  perspiration 
and  the  fluids  of  the  operating  room,  can  be  replaced 
by  his  (ordinary  dry  out-door  dress  and  the  reminders 
of  the  operating  room  are  left  behind. 

Preparation  of  Hands. — After  the  nails  are  filed 
.short  and  smooth  the  hands  and  forearms  should  be 
thorougldy  scruV)l)ed  for  fifteen  minutes  in  hot  water 
with  a  stiff  nail  brush  and  plenty  of  pure  soap.  The 
water  should  be  changed  at  least  five  times.  The  time 
should  be  estimated  by  an  actual  time  piece  and  not 


79 


by  guess  work.  A  nurse  should  supervise  this  part 
of  the  work  in  imx3ortant  operations,  and  report  to  the 
responsible  chief  any  laxity  on  the  part  of  any  partici- 
pant. The  spaces  beneath  the  nails  should  be  thor- 
oughly brushed  and  the  undersurface  of  the  nail 
scraped  with  a  steel  nail  cleaner.  After  the  soaj)  and 
water  scrubbing,  the  hands  should  be  washed  in  alco- 
hol and  then  immersed  in  1:1000  biohlorid  of  mercury 
solution,  and  this  solution  brought  into  contact  with 
all  irregularities  by  means  of  the  hand  brush.  The 
hands  should,  finally,  be  rinsed  in  warm  sterilized 
water.  Before  beginning  the  operation  the  hands 
should  be  rinsed  in  hot  water  which  is  placed  in  a 
basin  close  to  the  operator,  so  that  it  may  be  used  from 
time  to  time  during  the  operation.  After  the  hands 
are  once  washed  they  should  not  be  allowed  to  come 
in  contact  with  anything  before  or  during  the  opera- 
tion which  is  not  surgically  sterile. 

A7Tangetnent  of  OperatiiKj  Room. — The  steam  or 
dry  heat  sterilizers  containing  dressings  should  be 
convenient  to  the  nurse.  Reservoirs  of  sterilized 
water,  hot  and  cold,  should  be  i)laced  near  the  sponge 
table.  Two  large  glass  irrigators  should  be  at  hand. 
The  table  with  which  the  Trendelenburg  position  may 
be  obtained  is  necessary,  and  should  be  placed  in  an 
advantageous  position  for  light  and  assistants.  For  a 
laparotomy,  the  arrangement  of  the  furniture  and  par- 
ticipants of  the  operating  room  should  be  approxi- 
mately as  follows:  The  table  near  the  center  of  the 
room  with  the  head  of  the  patient  near  the  chief  win- 
dow. Anesthetizer  at  head  of  patient.  Operator  on 
right  of  table  (from  head).  Chief  assistant  and  assist- 
ants opposite  the  operator  with  the  chief  nearer  the 
head  of  the  table.  The  surgical  nurse  in  charge  of 
instruments  at  stand  to  right  of  operator.  Nurse  in 
charge  at  foot  of  table  with  sponge  dish  on  small 
stand  in  reach  of  second  assistant.  Assistant  nurse  to 
her  right,  the  latter  to  work  sponges,  and  to  attend  to 
irrigators,  sterilized  water,  etc.  Superintending  nurse 
without  regular  assignment,  ready  for  emergency.   To 


so 

left  of  operator,  small  table  with  sterilized  solution  for 
hands.  Back  of  the  assistants  a  similar  table.  Visit- 
ing physicians,  admitted  after  everything  is  ready  for 
the  operation  to  begin,  are  arranged  around  the  room 
out  of  reach  of  the  operating  corps,  or  any  concerned 
in  the  oi3eration. 

If  the  case  is  one  where  a  vaginal  operation  is 
required,  the  head  of  the  patient  is  directed  away 
from  the  window,  and  the  patient  in  the  exaggerated 
lithotomy  position  is  placed  with  the  buttocks  directed 
toward  the  light.  The  limbs  are  supported  on  either 
side  by  two  assistants.  The  operator  sits  at  the  foot 
of  the  table  with  the  instruments  at  his  right  hand. 
To  the  left  is  the  nurse  with  sponges  and  the  irrigator. 

PREPARATORY  TREATMENT  OF  PATIENT  FOR  LAPAROTOMY 
OR  VAGINAL  OPERATIONS. 

Kidneys. — The  failure  to  recognize  obscure  kidney 
disease  in  jiatients  before  submitting  them  to  a  severe 
operation  has  been  the  cause  of  many  avoidable  deaths. 
We  should  not  only  recognize  kidney  difficulties  in 
every  case  but  we  should  also  know  when  a  case  is 
laboring  under  some  form  of  kidney  trouble,  whether 
that  stage  has  been  reached  beyond  which  it  is  safe  to 
proceed.  It  is  not  enough  that  the  urine  in  any  given 
case  is  approximately  of  normal  quantity,  of  approxi- 
mately normal  specific  gravity,  and  that  it  gives 
negative  results  in  tests  for  albumin  and  sugar.  It  is 
necessary  to  learn  the  history  of  the  case,  to  estimate 
the  sijecific  gravity  in  a  twenty-four  hour  specimen,  to 
ascertain  the  amount  of  urea  for  twenty-four  hours, 
and  supplement  this  with  a  thorough  and  complete 
microscopic  examination. 

In  diabetes  we  should  not  operate.  In  interstitial 
nepl iritis  when  the  disease  is  not  far  advanced  an 
oi^eration  may  be  risked  with  proper  preparatory  treat- 
ment. These  latter  cases  arc^  tlie  very  ones  which  from 
their  great  difficulty  of  diagnosis  are  often  neglected, 
and  consequently  disaster  results.  The  importance  of 
the   suVjject   must   be   my  excuse  for   entering   into 


81 

primary  details.  The  following  summarizes  the  signs 
of  chronic  interstitial  nephritis:  Lowered  sj^ecific 
gravity  of  urine;  patient  arising  at  night  to  void 
urine  (when  there  is  no  bladder  or  urethral  disease 
to  give  rise  to  such  a  procedure);  an  enlarged  heart 
with  accentuated  second  sound;  a  tense  pulse  and 
diminished  urea.  Albumin  is  frequently  absent.  The 
diagnosis  is  doubly  sure  when  hyaline  casts  are 
found. 

Every  patient  should  be  scrutinized  in  all  these 
points.  If  the  foregoing  state  of  affairs  exist  to  a 
marked  degree  I  refuse  to  operate.  If,  however,  with 
the  above  symptoms  I  find  a  normal  quantity  of  urine, 
which  does  not  show  a  reduced  specific  gravity  under 
1010  to  1014  and  the  amount  of  urea  does  not  sink 
lower  than  six  or  seven  grains  to  the  ounce,  if  the 
patient  is  w^ell  preserved  generally  without  advanced 
heart  disease,  I  am  confident  that  I  can  operate  with 
safety,  if  I  can  secure  proper  preiDaration. 

I  i^repare  these  patients,  first  by  placing  them  on 
an  exclusive  farinaceous  diet  w^ith  miik  and  fruit  for 
an  indefinite  number  of  days  before  the  operation.  A 
week  or  ten  days  before  the  operation  a  diuretic  is 
added  with  instructions  to  drink  large  quantities  of 
water,  the  object  being  to  increase  the  daily  quan- 
tity of  urine  from  60  to  100  ounces,  in  order  to  thor- 
oughly flush  the  kidneys  and  rid  the  patient  of  dan- 
gerous accumulations.  With  60  to  100  ounces  of 
urine  flowing  for  several  days,  with  the  patient  living 
on  a  non-nitrogenous  diet,  with  the  urea  in  improved 
proportion  considering  the  diet,  I  feel  safe  in  risking 
an  operation. 

Dr.  Charles  W.  Purdy,  who  has  had  an  enormous 
experience  in  watching  the  behavior  of  kidney  diseases 
under  oj^erations,  says  in  reference  to  chronic  parcii- 
ch}jmafo}iS  nephritis:  "I  see  no  reason  why  these 
cases,  if  unaccompanied  with  dropsy  may  not  be  ope- 
rated upon  if  carefully  selected." 

Boivch. — In  prei^aring  patients  for  an  ordinary 
laparotomy  I  begin  preparations  of  the  bowels  two 


82 


nights  before  the  morning  of  the  operation.  The 
first  point  is  to  seek  thorough  emptying  of  the  bowels 
throughout  their  entire  length.  The  second  point 
should  be  to  render  their  contents  thoroughly  aseptic 
and  the  third  should  be  to  impart  to  them  a  maximum 
tonicity. 

The  bowels  are  emptied  by  means  of  mercurials  and 
salines.  The  first  night  of  ^preparation,  six  grains  of 
blue  mass  are  given.  The  next  morning  at  6  A.M.,  one 
drachm  doses  of  citrate  of  magnesia  are  given  every 
hour  until  the  bowels  move,  or  feel  as  though  they 
would  move  with  the  aid  of  a  small  enema.  This 
ought  to  insure  a  thorough  movement  of  the  entire 
length  of  the  intestinal  canal.  If  the  movements  are 
such,  with  the  above  treatment,  to  insure  a  thorough 
evacuation,  and  to  start  a  free  flow  of  bile,  as  indi- 
cated by  the  yellow  glistening  appearance  of  the  stool, 
no  further  catharsis  is  necessary.  The  lower  bowel 
should  be  thoroughly  evacuated,  however,  by  the 
employment  of  large  enemas  of  soap  and  water, 
repeated  four  or  five  times  during  this  second  day  of 
preiiaration.  The  last  enema  should  be  given  late  in 
the  afternoon  of  this  second  day  of  preparation,  if  the 
operation  is  to  be  done  the  following  morning,  and 
the  next  morning  if  the  ox)eration  is  to  bo  iDerformed 
in  the  afternoon.  The  bowels  are  rendei"ed  aseptic  by 
large  doses  of  bismuth  and  salol.  During  the  first 
and  second  days  of  jn-eparation,  gr.  x  of  salol  and  gr. 
XX  of  subnitrate  of  Insmuth  should  be  given  every 
six  hours. 

The  bowels  are  stimulated  by  means  of  carminatives, 
alcolujlic  stimulants  and  strychnin.  The  second  day  of 
I^rei^aration  1  drachm  doses  of  tr.  of  cardomon  in  one 
ounce  of  brandy  are  given  every  six  hours.  Strychnin 
is  commenced  three  days  before  Iho  o])eration  iii  1-40 
gr.  doses  every  eight  hours,  andgradually  increased  in 
quantity  until  1-20  gr.  doses  are  given.  The  bowels 
should  be  kejjt  in  a  thoroughly  as(^])tic  condition  by 
feeding  the  patient  a  milk  diet  for  two  days  lu'fore 
the  ojieration. 


83 


External  Preparations  of  the  Patient. — The  i&rst 
day  of  the  preparation  the  patient  should  receive  a 
thorough  general  bath  and  then  be  placed  in  clean 
clothing  and  a  clean  bed.  The  abdomen  should  then 
be  rubbed  with  a  saturated  solution  of  permanganate 
of  potassium  until  it  is  of  a  uniform  mahogany  color. 
This  should  be  scrubbed  off  by  means  of  a  si^onge 
or  brush  and  the  application  of  a  saturated  solution  of 
oxalic  acid.  A  green  soap  compress  should  be 
bound  on  the  abdomen,  this  latter  to  remain  all  night. 
Vaginal  douches  of,  first,  soap  and  water;  second, 
1 :5000  bichlorid  solution,  and  third,  plain  sterilized 
water  should  be  employed  this  first  night.  These 
should  be  repeated  the  night  before  the  operation, 
and  a  last  vaginal  douche  given  immediately  before 
the  operation.  The  second  night  of  preparation  should 
begin  with  shaving  of  the  abdomen  and  pubis,  and 
should  be  followed  by  applying  a  bichlorid  comjoress. 
Immediately  before  the  operation,  after  this  compress 
is  removed,  the  abdomen  should  be  scrubbed  with  green 
soap  and  hot  water,  this  to  be  followed  w4th  alcohol  or 
ether,  and  covered  with  an  antiseptic  towel  until  the 
incision  is  made. 

The  bladder  should  be  evacuated  by  means  of  a 
catheter  immediately  before  the  operation. 

Dress. — The  patient  is  to  be  put  in  a  long,  loose, 
woolen  night  gown  immediately  after  an  operation, 
and  is  thoroughly  covered,  except  the  abdomen,  with 
flannel  blankets  during  the  oi:)eration. 

Operation. — I  am  suspicious  of  an  operator  who 
operates  on  time.  The  best  operators  are  those  who 
oj)erate  w^ell  in  the  smallest  space  of  time;  this 
implies  that  the  best  operators  are  slow  operators. 
An  abdominrd  incision  should  be  a  clean,  true,  unhag- 
gled  cut,  so  that  accurate  coaptation  is  possible.  Cold 
sponges  should  be  employed  on  the  external  incision 
in  order  to  contract  the  capillary  vessels  and  check  their 
bleeding  without  the  necessity  of  forceps.  Forceps 
should  be  employed,  however,  everywhere  in  abdomi- 
nal surgery  that  their  use  will  save  blood,  because 


84 


most  of  our  old-fashioned  shock  was  caused  by  unnec- 
essary loss  of  blood.  Keep  the  operative  field  free 
from  oozing  points  if  possible,  even  at  the  loss  of  a 
little  time.  The  peritoneum  is  best  opened  between 
two  catch  forceps  elevated  so  as  to  present  a 
thin  fold.  After  a  small  opening  is  made,  the  finger 
passed  into  the  cavity  should  act  as  a  guide  upon  which 
to  complete  the  incision.  The  peritoneal  edges  should 
be  attached  to  the  integumentary  edges  by  means 
of  catch  forceps,  to  j)revent  its  peeling  off  from  the 
abdominal  walls  in  the  subsequent  manipulation.  In 
all  j)elvic  surgery  of  smaller  tumors  the  pelvis  should 
at  this  point  be  elevated  by  means  of  the  Trendelen- 
burg table ;  the  elevation  being  sufficient  to  draw  the 
bowels  away  from  the  field  of  operation,  and  to  elevate 
the  contents  of  the  pelvis.  Sterilized  silk  or  catgut 
should  be  employed  for  any  pedicle  which  it  is  safe  to 
tie  and  drop.  Catgut  may  be  employed  to  close  sim- 
ple peritoneal  rents. 

Drainage  should  be  employed  in  all  cases  where 
extensive  enucleation  has  occurred,  where  there  is  a 
slow  venous  oozing  from  separated  adhesions  or  where 
aseptic  matter  has  in  any  way  contaminated  the  peri- 
toneum. Drainage,  in  competent  hands,  never  does 
any  harm,  therefore,  where  there  is  the  slightest 
doubt,  it  should  be  employed.  It  has  saved  many 
lives,  and  made  more  comfortable  those  who  might 
not  have  died  without  it,  but  who  have  'been  given 
the  advantage  of  it. 

After  my  operation  is  finished,  the  peritoneal  cavity 
is  thoroughly  dried;  then  if  there  has  been  at  the 
operation  a  process  of  enucleation,  leaving  of  neces- 
sity slight  oozing  points,  or  in  cases  where  ordinary 
adhesions  have  bjeen  separated,  after  drying  the  cav- 
ity as  far  as  i)ossible,  I  place  in  the  cul-de-sac  a  glass 
drainage  tube  and  puirip  out  any  remaining  fluid. 
I  next  protect  the  abdominal  contents  from  the 
abdominal  wound  with  a  large  flat  sponge,  and  insert 
the  sutures^  after  which  I  again  pump  the  drainage 
tube.     If  there  is  more  than  a  drachm  of  bloody  fluid, 


85 


I  leave  the  tube  in  until  the  sutures  are  nearly  all  tied 
and  the  sponge  removed;  then  I  make  a  last  trial  of 
the  tube.  If  the  fluid  amounts  to  one-half  drachm  or 
more,  and  is  bloody,  I  allow  the  tube  to  remain;  if, 
on  the  contrary,  it  is  nearly  dry,  or  the  contents 
is  simply  colored  water,  the  result  of  flushing,  if 
it  has  been  employed,  I  remove  the  tube.  What  has 
been  done  influences  one  in  regard  to  drainage.  I 
almost  invariably  drain  after  it  has  been  necessary  to 
flush.  I  believe  the  peritoneum  is  satisfied,  to  an 
extent  by  the  flushing,  and  will  consequently  neglect, 
in  a  degree,  to  absorb  any  remaining  fluid.  Ex- 
perience seems  to  sustain  that  argument.  Mikulicz 
drain  is  almost  indispensable  in  a  limited  number  of 
cases.  Cavities  may  be  packed  with  gauze  which  can 
not  be  reached  with  glass  drainage  tubes.  Hemor- 
rhages in  cavities  so  packed  will  cease,  when  a  glass 
drain  would  not  avail.  Operations  are  now  possible 
with  the  Mikulicz  drain  which  were  impossible  with- 
out it.  The  question  about  drainage  is  not,  shall  we 
drain,  but  how,  and  how  often. 

To  Prevent  Intestinal  Ohstruction. — In  abdominal 
surgery  one  is  constantly  watching  the  behavior  of 
the  intestines.  They  are  our  prominent  point  of 
attack  in  our  preparatory  treatment,  they  are  our 
greatest  source  of  anxiety  during  the  operation,  and 
upon  their  management  after  the  oi3eration  much 
watchfulness  is  imposed.  All  of  this  anxiety  is  caused 
by  our  desire  (with  the  exception  of  care  against 
wounding  when  operating)  to  prevent  obstruction. 
It,  therefore,  is  a  point  in  the  technique  of  this  work 
to  which  discussion  may  profitably  be  directed. 

The  pathology  of  obstructions  is  well  summed  up 
by  a  valuable  contribution  on  this  subject  by  Dr. 
Ashton,  of  Philadelphia,  from  which  I  quote: 

"Adhesions  between  the  intestines  and  raw  sur- 
faces: a,  to  an  omental  stump;  b,  to  the  edges  of 
the  vaginal  wound  following  supra-pubic  or  vaginal 
hysterectomy ;  c,  to  a  pedicle ;  (/,  to  raw  surfaces  on 
the  intestinal  wall. 


86 


"2.  Paralysis  of  the  intestines. 

"3.  Local  spasm  of  the  intestines. 

'•■4.  Impacted  feces. 

"5.  Bands  of  inflammatory  lymph. 

''6,  Adhesions  between  coils  of  intestines  or 
between  the  gut  and  neighboring  parts,  due  to  trau- 
matic inflammation. 

"7.  Kinking  or  twisting  of  the  intestines,  due  to 
faulty  technique. 

"8.  Including  the  intestines  within  the  loop  of  a 
suture  of  the  abdominal  wall,  or  between  the  edges  of 
the  abdominal  incision. 

"9.  Slipping  of  a  coil  of  intestines  through  a  slit  or 
an  aperture." 

Under  the  first  head,  "Adhesions  between  the  intes- 
tines and  raw  surfaces,"  we  must  seek  our  remedy 
daring  and  following  the  ox3eration.  Intestines  should 
be  handled  and  ex^Dosed  as  little  as  possible  in  order 
not  to  produce  hyperemia  or  denudation  of  their  sur- 
faces. An  omental  stumj^  of  any  considerable  size 
should  be  selveged  by  inverting  its  raw  edges  with  a 
running  catgut,  or  with  ligature.  When  denudations 
of  the  pelvic  or  intestinal  pertioneum  can  not  be  rein- 
forced by  a  suj)erabandance  in  the  neighborhood,  care 
should  be  taken  to  carefully  arrange  the  intestines  in 
as  near  the  normal  position  as  jjossible.  A  pedicle  of 
large  size  should  be  covered  by  securing  over  its  end 
the  peritoneal  covering  with  a  running  stitch  of  cat- 
gut. Raw  surfaces  of  any  considerable  size  on  the 
inte.stines  should  be  covered  with  peritoneum  if  joossi- 
ble,  with  the  edges  well  secured.  Paralysis  of  the 
intestines  may  be  avoided  by  emptying  them  thor- 
oughly previous  to  the  operation  of  all  irritat- 
ing matter  (which  may  ferment  and  cause  dis- 
tensi(m )  by  rendering  the  contents  aseptic  by  means 
of  bismuth  and  salol,  and  the  employment  of  full 
doses  of  strychnia  to  act  as  a  muscular  tonic.  Car- 
minatives, such  as  wintergreen,  cardamon,  etc.  may 
also  be  employed  as  antiseptics  and  inuscular  tonics. 
During  the  oj^eration  the  intestines  should  not  be 


87 

handled  or  chilled  in  order  to  avoid  paralysis.  After 
the  operation,  nourishment  of  non-fermentive  and 
easily  absorbable  nature  should  be  employed.  The 
bowels  should  be  stimulated  to  early  action  in  order 
to  keep  them  empty  and  avoid  the  beginning  of  dis- 
tention, which  soon  leads  to  f)aralysis.  An  early  move- 
ment of  the  bowels,  or  free  passage  of  flatus,  assures  a 
normal  disposition  of  the  bowels  as  regards  location. 
If  they  adhere  after  such  time,  it  will  be  in  an  advan- 
tageous, not  cramped  position. 

A  flat  sponge  beneath  the  abdominal  wound,  after 
carefully  spreading  down  the  omentum  and  before 
the  wound  sutures  are  inserted,  will  avoid  including 
an  intestine  within  the  loop  of  a  suture,  or  between 
the  edges  of  the  abdominal  wound. 

When  ventral  fixation  of  the  uterus  is  practiced, 
great  care  should  be  exercised  in  disposing  of  the 
intestines  in  such  a  manner  as  to  avoid  their  slipping 
through  the  opening  left  between  the  uterus  and  the 
abdominal  wound. 

AFTER-TREATMENT. 

The  immediate  after-treatment  consists  in  stimulat- 
ing the  i^atient  out  of  any  tendency  to  nervous  shock 
which  may  exist.  She  should  be  surrounded  in  bed 
with  dry  heat,  and  in  hospitals  x^laced  on  a  water  bed. 
If  there  has  been  any  considerable  loss  of  blood,  the 
feet  may  be  elevated  in  order  to  restore  blood  pressure 
in  the  brain.  In  severe  cases  of  shock  from  loss  of 
blood,  it  is  well  to  bandage  the  blood  out  of  the  lower 
extremities  by  means  of  elastic  bandages.  A  saline 
solution  under  the  integument  may  assist  to  fill  the 
blood  vessels.  Oftentimes  the  difficulty  is  not  lack  of 
fluids  so  much  as  lack  of  tone,  which  allows  a  patient 
to  bleed  to  death,  as  some  one  has  put  it,  "into  her 
own  dilated  capillaries  and  venules."  Here  direct 
arterial  stimulants  and  vaso-constrictor  remedies  are 
called  for,  as  well  as  strong  nerve  stimulants.  la 
these  cases,  I  immediately  order  hypodermics  of  nitro- 
glycerin, strychnin  and  digatalin.     Stimulating  ene' 


88 

mas  of  whisky  and  warm  water  may  also  be  given. 
What  is  done  for  shock  should  be  done  promptly,  as 
patients  who  are  allowed  to  go  on  for  a  few  hours 
with  a  sub-normal  temperature  and  high  pulse,  are 
with  great  difficulty  restored. 

Dressing  Glass  Drainage  Tube. — The  glass  drain- 
age tube,  when  it  is  allowed  to  remain,  should  be 
emj^tied  with  a  syringe  with  a  long  rubber  nozzle  the 
first  time  in  one  hour.  If  the  fluid  is  more  than  a 
drachm  it  should  be  dressed  again  in  an  hour,  if  a 
drachm  or  less,  the  interval  between  dressings  should 
be  increased  one  hour,  and  the  same  rule  followed 
until  the  fluid  is  less  than  a  drachm  and  of  a  light 
amber  color,  and  the  interval  from  four  to  six  hours. 
At  this  time  the  tube  may  be  removed.  If  it  is  left 
longer  than  thirty-six  hours,  a  piece  of  sterilized 
gauze  should  be  put  in  its  place  for  six  hours,  when 
the  latter  is  removed  and  the  wound  is  closed  with 
slight  pressure  and  its  closure  is  obtained  by  extra 
pressure  of  external  straps. 

Care  of  Capillary  Gauze  Drain. — If  capillary  gauze 
drain  has  been  employed  instead  of  the  glass  drainage, 
the  protruding  gauze  (from  vagina  or  abdominal 
wound)  should  be  kept  abundantly  covered  with  a 
pad  of  loose  flufl'y  gauze,  and  this  should  be  changed 
as  often  as  it  becomes  saturated  with  fluids.  If  all 
drainage  ceases  in  twelve  to  twenty-four  hours  as  indi- 
cated by  dry  dressings,  the  gauze  packing  may  be 
removed.  However,  if  drainage  is  free  and  the  patient 
is  normal  it  may  remain  forty-eight  to  sixty-two  hours. 
When  it  is  possible  this  drainage  should  have  its  exit 
through  the  vagina.  After  it  has  been  removed  a 
loose  gauze  packing  should  be  placed  over  the  wound. 

Dressings. — The  wound  is  closed  with  silkworm 
gut,  including  all  parts  of  the  wound  edges,  and 
dusted  with  sterilized  iodoform,  and  the  dressing  is  a 
thick  one  of  iodoform  gauze,  held  in  place  by  adhe- 
sive straps  tight  enough  to  take  the  strain  off  the 
sutures  without  jjuckering  the  integument.  Over 
this  is  i)laced  a  liberal  allowance  of  absorbent  cotton. 


89 


and  all  retained  with  a  binder.  The  dressings  are  not 
disturbed  for  four  days  unless  there  is  pain  or  tem- 
perature. At  the  end  of  the  fourth  day  the  dressings 
are  carefully  removed,  and  the  wound  is  thoroughly 
but  carefully  washed  with  equal  parts  of  95  per  cent, 
alcohol  and  1:5000  bichlorid  solution.  Iodoform  is 
again  applied  and  the  dressings  renewed.  The  seventh 
day,  t>efore  the  stitches  are  removed,  I  again  have  the 
wound  washed  in  the  same  manner  and,  after  their 
removal,  dressed  as  before. 

In  vaginal  operations  the  vaginal  wound  is  dusted 
with  sterilized  iodoform  and  the  vagina  loosely  packed 
with  strij)  gause.  It  is  removed  m  forty-eight  hours 
and  after  twelve  hours  vaginal  douches  of  bichlorid 
of  mercury  solution  followed  by  plain  water  are  em- 
ployed once  or  twice  daily. 

Botvels  — If  flatus  has  not  passed  freely,  per  rectum, 
in  twelve  hours  by  the  simple  emj^loyment  of  a  rectal 
tube,  I  employ  the  "one,  one,  one"  enema,  one  ounce, 
of  sulj)hate  of  magnesia,  one  ounce  glycerin  and  one 
ounce  water.  If  this  does  not  start  the  gas  in  two 
hours,  I  order  it  repeated  in  double  quantity.  If  this 
enema  is  not  retained,  and  flatus  has  not  passed,  I 
order  an  enema  of  soap  and  water  one  ]3int,  with  one- 
half  drachm  of  turpentine.  If  they  are  still  obdurate, 
I  begin  one-half  grain  doses  of  calomel  in  ten  grains 
of  bicarbonate  of  soda,  given  every  two  hours  for  four 
doses,  or  until  gas  passes,  alternated  with  drachm 
doses  each  of  gran,  citrate  magnesia  and  sulphate 
magnesia  in  an  ounce  of  water.  Following  these  rem- 
edies in  one  hour,  another  "one,  one,  one"  enema  is 
given.  It  must  be  an  obstinate  case  indeed  that  will 
not  yield  under  the  above  remedies.  If  the  stomach 
is  irritable  and  will  not  tolerate  the  bicarbonate  of 
soda,  the  calomel  may  be  given  dry  on  the  tongue. 
Other  salines  may  be  substituted  for  the  above  if 
they  are  objectionable.  The  bowels  should  be  moved 
from  above  on  the  fifth  day  with  small  doses  of 
some  effervescing  salt,  or,  if  required,  a  more  vigorous 
laxative. 


90 


Diet. — First  week,  fluids;  second  week,  semi-solids; 
third  week,  semi-solid  and  solid  food  in  small  quanti- 
ties: fourth  week,  good  substantial  food,  with  a  few 
curtailments.  As  soon  as  the  patient  is  out  of  the 
anesthetic,  I  begin  to  give  hot  water  in  teaspoonful 
doses  as  often  as  every  fifteen  minutes.  If  the  stom- 
ach tolerates  this,  the  quantity  is  increased  to  one-half 
ounce,  and  the  interv^al  may  be  increased  in  length. 
If  the  patient  is  nauseated  and  the  hot  water  causes 
vomiting  (and  it  should  be  hot  water),  or  increases 
the  nausea,  it  should  be  withheld.  When  the  patient 
can  take  the  hot  water,  and  still  complains  of  thirst 
and  begs  for  cold  water  the  nurse  is  instructed  to  let 
her  rinse  her  mouth  with  cold  water.  Ginger  ale  is 
a  good  alternate  with  water  for  the  first  twenty-four 
hours.  After  twelve  hours,  drachm  doses  of  peptonized 
milk  may  be  sandwiched  with  the  water.  If  pepton- 
ized milk  is  offensive,  plain  sterilized  milk  may  be 
substituted,  or  sterilized  milk  and  lime  water.  Milk  in 
some  form,  I  feel  to  be  the  most  perfect  food.  It 
should  be  increased  every  hour  until  ^-  ounce  doses  are 
given  by  twenty-four  hours,  to  one  ounce  by  forty-eight 
hours,  and  to  two  ounces  by  the  end  of  sixty-eight 
hours.  Barley  water  may  be  alternated  with  the  milk 
Later,  the  monotony  may  be  relieved  with  the  meat 
and  shell-fish  broths,  thin  gruels,  etc.  The  fourth  or 
fifth  day  the  patient  may  be  allowed  to  extract  the 
juice  of  broiled  beef  by  chewing  it:  the  fiber,  of 
course,  should  be  rejected.  Tea  may  be  given  the 
second  or  third  day  as  a  relish.  Orange  juice,  and  the 
juice  of  other  fruits,  may  be  given  in  small  quantities 
the  third  or  fourth  day.  Rules  can  not  be  laid  down 
in  regard  to  the  diet  of  these  patients,  general  princi- 
ples only  can  be  hinted  at.  They)atientBhoukl  beseen 
each  day  and  her  wants  studied.  If  stimulants  are 
required,  one  of  the  best  is  good  brandy.  Chami^agn© 
is  all  right  if  its  sweetness  dcjes  not  make  it  objection- 
able. If  i)atients  are  unable  to  retain  enough  by 
stomach  to  properly  nourish  them,  enemas  of  either 
milk  or  stimulants  should  be  resorted  to. 


91 

Getting  Up. — Uncomplicated  laparotomy  cases  are 
gradually  bolstered  up  until  they  can  sit  in  a  bed  with 
a  bed  rest  at  about  the  fifteenth  or  sixteenth  day,  sit 
up  in  a  large  chair  at  the  twenty-first  day,  and  leave 
the  hospital  from  the  twenty-eighth  to  the  fortieth 
day. 


92 


LECTURE  VII. 


THE  author's  operation  OF  VAGINAL  LIGATION  OF  THE 
BROAD  LIGAMENT  AND  OTHER  MINOR  OPERATIONS. 


Vaginal  ligation  of  the  contents  of  the  base  of  the 
broad  ligaments,  for  the  cure  of  fibroids  of  the  uterus, 
was  devised  and  performed  by  me  as  a  new  and  original 
operation  Nov.  15,  1892,  and  was  described  and  pub- 
lished in  the  April  number  of  the  American  Journal 
of  Obstetrics  in  1893.  In  the  January  number  of  the 
American  Journal  of  Obstetrics,  1894,  I  reported  six 
cases  treated  by  the  new  operation. 

The  operation  as  originally  described  by  me  is  as 
follows:  The  ligation  of  more  or  less  of  the  broad 
ligament  of  the  uterus,  with  its  vessels  and  merves, 
the  extent  of  the  ligation  depending  upon  the  result 
sought,  from  a  simple  ligation  of  the  base  of  the  liga- 
ment, including  the  uterine  arteries  and  branches  of 
both  sides  without  opening  the  peritoneum  to  a  com- 
plete ligation  of  the  ligament  of  one  side,  including 
both  uterine  and  ovarian  arteries,  with  partial  ligation 
of  the  opposite  ligament  without  opening  the  peri- 
toneal cavity,  if  possible,  but  by  doing  so  if  necessary. 

The  results  sought  in  the  operation  are,  first  to 
check  uterine  hemorrhages  by  cutting  off  blood  chan- 
nels, and  secondly  to  produce  atrophy  of  the  fibroid  by, 
1,  depriving  it  of  nourishment  through  the  blood  ves- 
sels and,  2,  by  changing  the  nutrition  of  the  uterus 
by  interfering  with  its  nerve  supply. 

Immediately  after  publishing  my  first  article  on 
this  operation  there  were  two  claimants  for  priority; 
Dr.    Walter  B.   Dorsett,   of  St.  Louis,  and  Prof.  S. 


ys 


Gottschalk,  of  Berlin,  Grermany.  Dr.  Dorsett,  in  a 
letter  to  the  American  Jonrndl of  Obstetrics,  claimed 
that  he  had  suggested  a  similar  procedure  to  my  oper- 
ation in  an  article  he  published  in  the  St.  Louis  Cour- 
ier of  Medicine  in  1890,  the  article  bearing  title  of 
"A  Case  of  Atrophy  of  the  Female  Genitalia  fol- 
lowing Pregnancy  and  remarks."  In  this  article  he 
made  the  following  observation:  "I  believe  that  in 
the  treatment  of  uterine  fibroid  .  .  .  to  ligate 
the  uterine  artery  would  not  be  an  unscientific  pro- 
cedure. On  the  contrary  the  more  I  have  thought 
of  it  the  more  I  am  inclined  to  believe  that  it  would 
be  the  most  certain  mode  of  treatment."  Dr.  D.^r- 
sett,  while  advancing  the  theory,  had  not  at  that 
time  carried  it  out  on  a  living  woman. 

Prof,  Gottschalk  based  his  claim  of  priority  on  an 
article  read  by  him  at  the  Brussels  Congress,  Sept. 
16, 1892,  with  the  following  title:  "  Die  Histogenese 
und  Aetiologie  der  Uterusmyome."  In  the  latter 
paragraphs  of  this  article  he  casually  suggested  liga- 
tion of  the  uterine  arteries  and  stated  that  he  had 
performed  the  operation  twice.  This  is  what  he  said: 
"The  bilateral  ligation  of  the  uterine  arteries  ap- 
pears to  be  the  therapeutic  measure  in  this  regard 
for  the  earliest  incii3ient  stages  of  myoma.  This 
offers  no  difficulties  in  its  technique;  it  is  easily 
performed  in  a  few  minutes.  .  .  I  have  already 
performed  this  ligation  in  two  cases  in  which  I  was 
able  to  early  diagnose  the  development  of  multiple 
myoma  with  best  results." 

Thus  these  two  men  both  suggested  tying  the 
uterine  arteries  for  the  cure  of  fibroids  and  at  least 
one  of  them  (Gottschalk)  jjerformed  the  operation 
twice  before  I  described  my  operation.  This  would 
definitely  decide  the  question  of  priority  in  their 
favor  if  the  operation  they  suggested  was  identical 
with  mine.  Their  operation  is  not  identical  in 
theory,  in  execution,  or  in  description  with  mine, 
and  therefore  their  claim  of  priority  for  ni}-^  opera- 
tion can  not  be  substantiated. 


94 


The  operation  suggested  by  these  men  simply  in- 
■cludes  the  ligating  of  the  uterine  artery  from  the 
vagina,  while,  1,  I  ligate  in  all  cases,  the  whole  base 
of  the  broad  ligament,  in  order,  a,  to  occlude  not 
only  the  main  channel  of  the  uterine  artery,  but  all 
collateral  branches;  6,  in  order  to  destroy  the  func- 
tion of  the  nerves  as  well  as  the  arteries  of  nutri- 
tion; c,  in  order  to  diminish  nerve  reflexes.  2.  I 
include,  in  desperate  cases,  not  only  the  base  of  the 
broad  ligament  with  the  uterine  artery  and  branches 
in  my  ligatures,  but  when  practicable  ligate  high 
enough  on  one  side  to  take  in  the  ovarian  artery. 
3.  I  advise  accomplishing  this  result,  if  possible, 
without  opening  the  peritoneal  cavity,  but  by  doing 
so,  if  necessary. 

TECHNIQUE    OF   OPERATION. 

The  preparation  of  a  patient  for  vaginal  ligation 
of  the  broad  ligaments  of  the  uterus  should  be  sim- 
ilar to  that  demanded  for  vaginal  hysterectomy,  as 
described  in  my  Lectures  VI  and  IX.  Ether  is  used  as 
an  anesthetic  and  the  patient  is  placed  on  the  operat- 
ing table  in  the  exaggerated  lithotomy  position  with 
buttocks  brought  to  the  end  of  the  table,  with  an  assist- 
ant on  either  side  to  support  the  limbs  and  hold  the 
vaginal  retractors.  A  broad,  short  vaginal  retractor 
above  and  below  exposes  the  cervix,  which  is  trans- 
fixed with  a  strong  silk  ligature  to  be  employed  in 
handlinLc  the  uterus.  The  uterine  canal  is  dilated  and 
the  uterine  cavity  curetted  with  a  dull  curette  and 
thoroughly  irrigated  with  1:1000  bichlorid  solution 
and  then  loosely  packed  with  iodoform  gauze.  This 
procedure  cleans  the  uterus  and  makes  it  impossible 
for  the  vaginal  wounds  to  become  infected  by  a  septic 
uterine  discharge.  The  uterus  is  now  drawn  down  in 
order  to  jjut  the  broad  ligaments  on  the  stretch  and 
then  drawn  to  the  right  side  so  as  to  expose  the  left 
vaginal  vault.  The  mucous  membrane  of  the  vagina 
at  the  utero- vaginal  fold  on  the  left  side  is  tlieu^ 
caught  with  a  tenaculum  and  incised  with  a  i)air  of 


95 


curs^ed  scissors.  One  blade  is  allowed  to  enter  beneath 
the  mucous  membrane  and  a  curved  incision  one  and 
one-half  to  two  inches  long  is  made  over  the  broad 
ligament  and  at  right  angles  to  it  (Fig.  15).  By 
means  of  the  index  fingers  of  the  two  hands  the  oper- 


,^^'*i-/'.., . 


''JnW 


Figure  lo. 


ator  now  separates  the  vaginal  tissue  from  the  broad 
ligament  and  carefully  separates  the  broad  ligament 
in  front  from  the  bladder  for  a  height  of  two  inches 
and  laterally  for  nearly  the  same  distance  (Fig.  K)). 
The  bladder  should  be  carefully  separated  in  this  way 
in  order  to  avoid  the  danger  of  wounding  the  organ, 


96 


and  by  pushing  the  separation  laterally  the  ureter  is 
forced  out  of  danger.  One  then  carefully  separates  the 
broad  ligament  posteriorly  to  the  same  height  as  in 
front,  without,  if  i^ossible,  penetrating  the  peritoneum. 
Now,  by  passing  one  finger  behind  the  other  in  front, 
the  whole  base  of  the  broad  ligament,  representing  two- 


FlGURE   10, 


Figure  17. 


thirds  of  its  bulk,  can  be  grasped  (Fig.  17)  foradistance 
of  an  inch  to  an  inch  and  a  half  from  the  uterus.  In 
this  grasp  one  can  easily  feel  the  throb  of  the  main 
trunk  of  the  uterine  artery  and  occasionally  several 
branches.     The  curved  pedicle  needle  is  then  passed, 


97 


armed  with  No.  10  silk,  strong  pyoktaninized  catgut  or 
kangaroo  tendon,  and  guided  by  the  index  finger  of  the 
left  hand  (Fig.  18)  is  made  to  jDenetrate  through  the 
broad  ligament.  The  ligature  is  drawn  through,  the 
needle  removed  and  the  base  of  the  broad  ligament  is 
thoroughly  ligated  at  a  distance  of  one  inch  or  more 
from  the  uterus.     The  ligature  is  cut  short,  leaving  it 


Figure  18. 


Figure  19. 

buried  in  the  tissues.  The  other  broad  ligament  is 
treated  in  the  same  manner;  the  vagina  is  well  steri- 
lized with  bichlorid  solution  and  the  vaginal  incision 
accurately  approximated  with  fine  antiseptic  catgut  so 
as  to  completely  bury  the  broad  ligament  ligatures 
(Fig.  19).  The  handling  string  is  now  removed  from 
the  cervix,  and  the  end  of  the  gauze  strip  packed  in 


98 


the  uterus  is  tied  to  another  strip  and  the  vagina  is 
filled  loosely  with  a  gauze  drain. 

The  after  treatment  of  these  cases  is  very  simple. 
The  vaginal  and  uterine  gauze  is  removed  tho  second 
or  third  day,  and  twice  a  day  thereafter  a  bichlorid 
vaginal  douche  1 :2000  followed  by  plain  douche  are 
given  =  Figure  20  shows  the  joosition  of  ligatures 
when  only  the  base  of  the  broad  ligament  is  ligated. 


Figure  20. 


SELECTION  OF  CASES. 

Interstitial  fibroids  of  the  uterus  of  moderate  size 
are  the  cases  in  which  the  best  results  will  be  o})tained 
by  this  operation.  Subi:)eritoneal  fibroids  sijringing 
from  the  fundus  of  the  uterus  especially  would 
scarcely  be  benefited  to  any  great  extent  by  depriving 
the  lower  part  of  the  uterus  of  its  nourishment. 
Neither  would  one  expect  to  obtain  any  lasting  ben- 
efit from  this  oj)eration  in  cases  of  pedunculated  sub- 
mucous fiVjroids.     On  the  other  hand,  in  true  intersti- 


9U 


tial  growths  depending  upon  the  whole  uterus  for 
their  nourishment,  cases  where  the  tumor  is  the 
uterus,  and  these  represent  75  per  cent,  of  all  fibroids 
of  the  uterus,  wherever  it  is  possible  to  tie  the  base  of 
the  broad  ligament  from  the  vagina,  this  operation 
may  be  expected  to  accomplish  prompt  and  decided 
relief  of  symptoms  and  a  rapid  reduction  of  the  tumor. 
The  cases  in  which  the  most  satisfactory  results  must 
be  exj)ected  are  incipient  or  small  fibroids  of  the  in- 
terstitial variety  which  show  themselves  late  in  the 
menstrual  life.  Here,  we  have  a  uterus  which  is 
small  enough  so  that  it  has  not  risen  above  the  brim 
of  the  pelvis,  one  which  can  be  easily  reached  from 
the  vagina  so  that  its  broad  ligaments  are  accessible 
from  below.  Such  a  fibroid,  too,  from  the  age  of  the 
patient  will  reach  a  state  of  quiescence  as  soon  as  the 
menopause  is  established.  In  such  cases,  then,  a  major 
operation  is  particularly  undesirable,  because  it  is  not 
imperatively  demanded  and  because  of  a  reasonable 
chance  of  relief  at  the  approaching  change;  on  the 
other  hand  the  symptoms  (with  severe  hemorrhage 
usually  as  the  principal  one)  are  such  that  immediate 
relief  is  earnestly  sought,  if  one  can  be  reasonably 
certain  of  obtaining  it  without  submitting  to  a  dan- 
gerous and  radical  procedure.  These  are  ideal  cases 
for  this  operation. 

Another  class  of  cases  in  which  this  operation  has 
been  employed  with  gratifying  success  and  in  which 
it  will  j)robably  find  favor  with  the  most  radical  oper- 
ators, are  those  of  continuous  and  profuse  hemor- 
rhage in  which  the  desperateness  of  the  drain  is  such 
that  the  patients  are  depleted  to  such  a  degree,  that  no 
radical  procedure  can  be  thought  of,  until  a  minor 
operative  procedure  has  checked  blood  waste  and 
recuperation  is  accomplished.  My  fourth  and  sixth 
cases  were  like  the  above.  In  the  fourth  case  hemor- 
rhage was  very  profuse  and  the  patient  was  completely 
exsanguinated  and  so  weak  that  she  had  not  been  out 
of  bed  for  several  months.  Some  time  before  I  deter- 
mined to  submit  her  to  my  operation  an  attempt  had 


100 

been  made  to  remove  the  appendages,  or,  if  possible, 
when  the  laparotomy  was  in  progress,  the  uterus. 
From  complicated  adhesions  and  the  weakness  of  the 
subject  neither  operation  was  possible  after  the  abdo- 
men had  been  opened.  The  tumor  was  large  and  the 
elevation  of  the  uterus  in  consequence  was  great,  and 
it  was  with  the  utmost  difficulty  with  the  aid  of  the 
most  competent  assistants,  that  I  finally  succeeded  in 
ligating  thoroughly  the  base  of  each  broad  ligament. 
Both  ligaments  contained  several  arteries,  some  of 
them  as  large  as  the  normal  radial  artery.  They  were 
all  tied  in  mass.  Hemorrhage  stopped  from  the 
instant  of  tying  the  last  ligature  and  it  has  never 
recurred.  It  has  now  been  over  three  years  since  I 
operated  on  this  case.  The  uterus  has  reduced  until 
it  is  but  slightly  larger  than  normal.  The  woman  (I 
examined  her  but  a  few  months  ago)  is  perfectly  well. 
She  has  a  slight  menstrual  flow  each  month,  and  is 
free  from  pain. 

Case  six  was  of  a  severe  hemorrhagic  nature  in  a 
typical  interstitial  fibroid  of  three  by  five  inches  in 
diameter.  The  woman  was  too  weak  and  dei^leted  for  a 
radical  operation.  I  did  my  operation  on  her  and  the 
result  was  marvelous.  In  three  months'  time  she  had 
recuperated  so  that  any  radical  ojjeration  might  have 
been  done  without  danger. 

Dr.  Humiston,  of  Cleveland,  reported  to  me  a  case 
in  which  he  used  my  operation  as  a  procedure  of  last 
resort,  in  a  patient  nearly  moribund  from  hemorrhage. 
She  was  so  weak  that  he  only  attempted  ligation  on 
one  side.  The  woman  stopped  bleeding  instantly  and 
eventually  recovered.  Hence,  the  operation  may  with 
propriety  V)e  employed  as  a  rational  temporary  expe- 
dient in  desperate  cases  of  whatever  variety,  where 
uterine  blood  loss  is  conspicuous. 

CASES. 

In  selecting  cases  for  this  operation  I  have  been 
very  careful.  In  the  majority  of  them  I  have  oper- 
ated on.  there  seemed  no  alternative.     All  were  des- 


101 


perate  ones,  like  cases  1,  2,  3,  6  and  8,  or  they  would 
not  submit  to  a  more  radical  i^rocedure,  and  milder 
means,  as  electricity,  ergot,  etc.,  would  not  accomplish 
satisfactory  results.  I  have  been  more  conservative 
in  adopting  the  operation,  I  am  afraid,  than  the  results 
in  the  few  cases  I  have  o^Derated  on  would  justify. 
One  reason  for  not  adopting  the  operation  in  a  larger 
number  of  cases  is  that  I  wished  first  to  learn  of  the 
remote  results.  It  is  now  over  three  years  since  my 
first  operation  and  most  of  the  operations  which  I 
have  performed  were  during  the  first  year.  I  have, 
therefore,  a  three  years'  history  to  analyze  in  the 
majority  of  my  cases.  In  the  following  report  there 
are  no  instances  in  which,  at  least,  a  year  has  not 
elapsed  since  the  operation. 

Case  1. — This  was  an  interstitial  fibroid  in  a  maiden  lady  36 
years  old,  in  size  extending  above  the  umbilicus.  The  hem- 
orrhage was  exhaustive  and  the  patient  greatly  reduced  in 
consequence.  Her  heart  was  hypertrophied  and  her  con- 
dition was  such  that  no  surgeon  with  a  proper  care 
•for  his  statistics  or  his  patient's  life  would  have  ven- 
tured a  hysterectomy.  She  was  operated  on  by  my  oper- 
ation Nov.  15,  1892.  The  hemorrhage  decreased  about  one- 
half  for  several  months  after  the  operation.  The  tumor  in 
the  first  four  months  materially  decreased  in  size.  In  May, 
1894,  the  hemorrhage  is  reported  much  modified,  and  no 
longer  a  source  of  alarm.  The  patient  at  that  date  considered 
her  condition  greatly  improved,  hemorrhage  cured,  tumor 
materially  reduced  and  pressure  symptoms  subsided,  March 
12,  1896,  four  years  and  three  months  after  the  operation  the 
patient  reports  herself  well.  The  original  fullness  produced 
by  the  tumor  she  can  no  longer  feel.  No  pain.  The  last  flow- 
ing of  any  consequence  was  November,  1894.  Since  then  the 
flow  has  been  very  slight  until  last  July,  when  it  practically 
ceased.  "I  have  color  in  my  lips  and  cheeks.  I  walk  two 
miles  or  more  every  day,"  she  writes.  This  report  is  certainly 
very  gratifying. 

Case  2. — The  second  case  was  a  married  woman  40  years  of 
age  who  had  been  under  electrical  treatment  for  a  hemorrhagic 
myofibroma  of  the  uterus.  The  galvanism  decreased  the  size 
of  the  growth  but  did  not  materially  lessen  the  exhaustive 
hemorrhage.  The  tumor  was  of  the  interstitial  variety  and 
the  uterus  appeared  the  size  of  a  three  months'  pregnant 
uterus.  When  the  patient  entered  the  Woman's  Hospital  for 
operation  December,  1892,  she  had  been  having  almost  contin- 
uous hemorrhage  for  several    months.     Upon   exposing   the 


102 


uterus  with  the  retractors  at  the  time  of  the  operation,  the  cer- 
vix was  large,  blue  and  vascular.  As  the  vagina  was  large  the 
operation  was  very  easily  executed.  The  ligature  on  the  left 
side  included  fully  two  inches  in  width  of  the  broad  ligament 
at  a  distance  of  at  least  an  inch  from  the  uterus.  When  I 
tightened  this  first  ligature  one  of  the  spectators,  a  well  known 
gynecologist,  called  my  attention  to  the  fact  that  the  cervix 
had  perceptibly  paled  in  appearance.  The  broad  ligament  was 
easily  exposed  on  the  right  side,  and  fully  as  much  of  it  ligated 
as  on  the  left.  If  there  had  been  any  doubt  of  the  procedure 
affecting  the  vascularity  of  the  uterus,  it  vanished  when  the 
second  ligature  was  tied.  The  cervix  immediately  paled  until 
it  was  nearly  as  white  as  a  piece  of  cartilage. 

The  covering  of  the  broad  ligament  was  so  loosely  attached 
in  this  case  that  I  could  easily  feel  the  main  channel  of  the 
ovarian  artery,  and  it  would  have  been  an  easy  matter  to  have 
included  it  in  the  ligature. 

After  over  three  years  I  can  promise  this  case  a 
perfect  cure.  The  uterus  has  reduced  to  normal  size. 
The  hemorrhage  has  ceased  completely.  All  pain  has 
disappeared.  A  slight  menstruation,  normal  in  quan- 
tity, occurs  each  month.  The  patient's  health  has 
improved  so,  that  from  a  state  of  almost  complete 
invalidism  she  is  transformed  into  to  a  strong  healthy 
woman.  The  improvement  has  been  progressive  from 
the  day  of  the  operation.  I  have  seen  this  case  within 
the  month  (March  1896). 

Cane  3. — This  patient  was  operated  on  in  January,  1893.  She 
had  an  incipient  interstitial  fibroid  of  two  years'  standing 
which  was  profusely  hemorrhagic  in  nature.  I  tied  the  base 
of  both  broad  ligaments  including  the  uterine  arteries  and 
their  branches.  The  relief  was  immediate.  The  menstrua- 
tion for  the  next  four  months  was  scanty.  The  patient  gained 
in  health  and  strength  rapidly.  The  tumor,  which  was  the 
size  of  a  four  months'  pregnancy  at  the  time  of  the  operation 
decreased  markedly  in  size  within  three  months.  Four 
months  after  the  operation  I  lost  track  of  this  case,  as  she 
lived  m  a  distant  State  and  neglected  to  keejj  me  jjosted.  Her 
last  letter  gave  a  rejjort  of  perfect  health. 

CVi.sY:!  4.  This  patient  had  a  large,  bleeding  fibroid  filling  the 
I^clvis,  which  extended  to  the  umbilicus.  The  uterus  and 
appendages  were  firmly  adherent  and  immovable.  Laparotomy 
had  been  attempted  on  the  case,  with  the  object  of  removing 
the  appendages  or  the  tumor.  The  abdomen  was  opened,  but 
the  adhesions  and  unusual  complications  rendered  it  impossible 
t()  remove  the  tumor  or  even  accomi)lish  the  oblation  of  the 
appendages.     The  patient  was  so  unusually  reduced  from  loss 


lOi 


of  blood  at  the  time  of  my  operation  that  she  had  not  been 
able  to  be  out  of  bed  for  three  months. 

I  operated  on  the  jjatient  in  January,  1893,  at  the  Post- 
Graduate  Medical  School  of  Chicago,  The  operation  was 
accomplished  with  great  difficulty  because  of  the  large  size  and 
immovability  of  the  uterus.  Finally,  however,  after  consum- 
ing more  than  an  hour  in  time  I  succeeded  in  ligating  thor- 
oughly the  two  broad  ligaments  well  above  the  uterine  arteries 
and  their  branches. 

In  June  following  I  made  the  following  report  on  the  case  : 
"The  flowing  ceased  immediately  and  the  patient  was  relieved 
of  her  drain  for  over  two  weeks.  She  then  had  a  few  days' 
flowing,  which  resembled  an  ordinary  menstruation.  She  has 
rapidly  and  steadily  improved  since  that  time.  She  has  men- 
struated regularly  but  scantily,  and  without  pain.  She  can  at 
this  time  (June,  1893),  five  months  after  the  operation,  attend 
to  her  duties  as  a  housewife,  and  considers  herself  cured.  The 
tumor  has  become  reduced  in  size  until  it  is  no  longer  notice- 
able as  a  deformity,  and  so  that  the  patient  herself  is  no  longer 
conscious  of  its  presence." 

Since  the  foregoing  report  was  written  in  June,  I 
have  seen  this  patient  several  times,  the  last  time 
within  the  month.  The  patient  was  then  examined 
by  several  physicians,  one  or  two  of  whom  on  inde- 
pendent examinations,  failed  to  notice  any  abnormal 
enlargement.  The  uterus  is  still  somewhat  larger 
than  normal,  but  is  not  more  than  three  or  four  inches 
in  diameter,  while  the  testimony  of  at  least  three  exper- 
ienced diagnosticians  will  bear  me  out  in  the  estimate 
that  its  former  diameters  were  not  less  than  four  and 
a  half  by  eight  inches.  The  patient  is  in  good  health 
now,  Jan.  1,  1895;  menstruation  is  regular  but  scanty, 
and  she  is  free  from  pain.  The  patient,  so  far  as  I 
know,  has  remained  well. 

Case  5. — This  case  was  a  woman  with  an  interstitial  fibroid 
about  three  by  five  inches.  She  was  about  30  years  of  age,  and 
the  growth  had  been  noticed  for  three  years.  Her  principle 
symptoms  were  profuse  menorrhagia  with  severe  menstrual 
pain.  The  case  was  referred  tomeby  Dr.  F.  H.  Greer,  of  Colum- 
bus, Neb.  I  did  my  operation  on  the  woman  Jan.  8,  1893.  She 
had  a  little  subsequent  temperature,  and  one  month  after  the 
operation  the  ligature  sloughed  from  the  left  broad  ligament. 
Four  months  after  the  operation  Dr.  Greer  reports  the  woman 
V(^ell.  "Menstruation  scanty,  no  pain.  Fibroid  diminished  in 
size  until  the  uterus  is  about  normal.     Patient  claims  that  she 


104 


is  cured."  This  report  was  made  in  June,  1893.  I  iiave  been 
unable  to  get  any  history  subsequent  to  that  date. 

Case  6*. — This  was  the  wife  of  a  physician  of  more  than  ordi- 
nary abihty  and  reputation.  The  patient  was  about  36  years  of 
age,  slightly  above  the  average  height,  with  well-proportioned 
frame,  but  poor  in  flesh,  with  a  skin  blanched  and  a  body  almost 
exsanguinated.  The  uterus  was  about  the  size  of  a  three 
months'  gravid  uterus.  The  tumor  was  uniform  and  evidently 
interstitial.  The  uterus  was  in  normal  position.  The  cervix 
was  nearly  two  inches  in  diameter,  the  os  patulous. 

The  history  of  the  growth  dated  back,  undoubtedly,  several 
years.  The  patient  had  borne  no  children.  The  menstruation 
had  for  nearly  two  years  increased  in  quantity  and  duration, 
until  now,  while  coming  with  absolute  regularity,  it  lasted  fifteen 
days,  and  that  in  spite  of  vaginal  and  uterine  tampons,  the  re- 
cumbent position,  ergot,  hydrastisand  the  rest.  She  flowed  each 
month  until  she  was  completely  exhausted,  scarcely  recovering  in 
the  next  thirteen  days  sufficiently  so  that  she  could  assume  the 
upright  position  without  fainting.  Accompanying  this  unusual 
discharge  was  uterine  pain,  which  in  its  severity  brought  the 
patient  to  the  point  of  unconsciousness.  During  the  four  days 
in  which  the  woman  could  drag  herself  around  in  the  latter 
part  of  each  intermenstrual  period  she  did  so  with  the  greatest 
discomfort  on  account  of  the  pressure  and  neuralgic  pains  of 
the  pelvis.  Upon  examination  of  the  broad  ligament  from  the 
vagina  the  finger  could  detect  on  either  side  the  large,  pulsat- 
ing artery  as  it  fed  the  tumor.  The  latter  was  movable,  the 
appendages  apparently  normal,  the  broad  ligaments  accessible. 
In  fine,  here  was  an  ideally  typical  case — a  hemorrhagic  fibroid 
of  the  uterus,  a  bed-ridden  patient,  an  authentic  diagnosis,  an 
unusually  interested  physician  to  carefully  watch  and  estimate 
the  result,  and  one  who  enthusiastically  demanded  a  trial  of  the 
new  operation.  Under  the  circumstances  it  seemed  to  me  that 
much  depended  upon  this  case,  as  though  the  fate  of  this  oper- 
ation must  necessarily  be  more  than  usually  linked  with  this 
particular  patient. 

I  operated  on  this  case  Aug.  2,  1894,  at  the  Chicago  Hospital, 
with  Dr.  Robert  Dodds  and  Dr.  Oksschct  as  assistants.  The 
left  broad  ligament  was  carefully  dissected  from  the  peritoneal 
covering  behind,  and  from  the  bladder  in  front,  until  fully 
two  thirds  of  it  could  he  grasped  by  placing  one  finger  behind 
it  and  another  finger  or  instrument  in  front  of  it.  When 
{.'r.ifif;ed  in  this  manner  several  beating  branches  of  the  uterine 
art<-ry,  together  with  the  main  artery  itself  could  be  detected. 
This  entire  mass  was  then  ligated  in  two  sections  with  No.  12 
braided  silk,  the  silk  cut  short,  the  parts  irrigated  and  the 
vaginal  wound  closed  with  catgut.  After  treating  the  opposite 
side  in  the  same  manner,  the  vagina  was  cleansed  and  loosely 
jjacked  with  iodoform  gauze.  When  the  operation  was  finished 
the  throbbing  arteries,  which  could  be  distinctly  felt  before, 


105 


could  no  longer  be  found.  The  cervix,  which  was  large  and 
prurplc  previous  to  the  operation,  became  pale  and  cartilagin- 
ous in  appearance  as  soon  as  the  ligaments  were  secured. 

The  patient  remained  in  the  hosiDital  three  weeks. 
The  first  menstruation  was  due  the  day  following  the 
operation.  It  began  the  next  morning,  but  was  so 
slight  and  painless  that  the  patient  would  not  believe 
that  it  was  her  menstruation  until  several  days  had 
elapsed  and  no  other  flow  apjDeared.  It  lasted  about 
three  days  and  was  barely  perceptible;  absolutely  no 
pain.  The  after  treatment  consisted  in  vaginal 
douches  after  removing  the  gauze,  light  diet  and  the 
recumbent  position  for  two  weeks. 

August  30,  the  second  menstruation  reappeared; 
there  was  a  little  of  the  old  pain,  but  not  sufficient  to 
require  anodyne  of  any  kind;  the  flow  was  half  the 
usual  amount  and  lasted  six  days.  September  28,  the 
third  menstruation  appeared;  the  amount  was  normal 
in  quantity,  lasting  but  four  days;  the  pain  was 
slight.  October  26,  the  fourth  menstruation  appeared; 
the  amount  normal  in  quantity,  lasting  but  four 
days;  the  pain  was  slight.  The  patient  was  seen  and 
examined  by  me  just  before  the  last  menstruation. 
She  had  gained  several  pounds  in  flesh,  her  cheeks 
and  lips  were  red  and  she  was  a  i^icture  of  health  and 
robustness.  Her  feelings  were  in  accord  with  her 
appearance,  as  she  enthusiastically  assured  me  that  she 
felt  perfectly  well.  On  examination  I  found  the 
uterus  was  reduced  in  size.  It  was  little,  if  any, 
larger  than  normal.  Its  bulk  had  decreased  one-half. 
The  cervix  was  small  and  normal.  No  arterial  pulsa- 
tion could  be  felt  in  either  broad  ligament  or  around 
the  vault  of  the  vagina. 

The  next  report  I  received  was  in  January,  1894: 
"  I  have  to  report,"  the  husband  says,  "  that  Mrs.  X. 
menstruated  from  December  19  to  21:.  That  the 
amount  was  about  the  same  as  before,  /.  c,  slightly 
above  the  normal.  Pain  rather  excessive  for  two  days 
(possibly  due  to  rheumatism  and  neuralgia).  After 
flow  had  ceased  I  examined   and  found  liGfature  in 


105 


vagina  and  also  small  sinous  opening  to  left  side  of 
cen'ix.  Since  then  ihere  has  been  slight  discharge 
from  same.  She  had  been  suffering  some  pain  at 
that  point,  no  pain  since  ligature  came  away."  He 
adds  enthusiastically:  ''Taken  all  in  all,  the  result 
so  far  is  a  grand  success."  Jan.  17,  1894,  he  writes: 
"  Mrs.  X.  is  up  to-day  (the  fifth  day)  after  the  easiest 
menstruation  she  has  had  in  her  life;  pain  moderate 
and  only  one  day.  This  in  face  of  the  right  side  still 
discharging.  In  the  next  two  months  I  exjDect  to 
have  a  well  woman.  The  uterus  is  no^7  practically 
normal." 

I  have  lost  track  of  this  patient  entirely,  and  I 
regret  that  I  am  unable  to  complete  so  interesting  a 
history.  If  the-  husband  of  this  patient  should  read 
this  report  I  hope  that  he  will  communicate  with  me. 

Case  7. — Mrs.  S.,  Denver,  Colo.,  aged  35,  uterus  about  double 
the  normal  proportions,  containing  two  or  more  centers  of  de- 
velopment and  an  extremely  hemorrhagic  tendency,  was  the 
seventh  case  operated  on.  The  case  had  been  treated  unsuc- 
cessfully by  curettement,  electricity  and  the  ordinary  remedies 
for  checking  uterine  hemorrhages.  The  uterus  was  retroverted 
but  free  from  adhesions.  The  patient  was  prepai;ed  carefully, 
and  at  the  Woman's  Hospital,  on  Nov.  11,  189.3,  1  ligated  the 
base  of  both  broad  ligaments,  and  shortened  the  round  liga- 
ments. The  uterus  was  drawn  well  down,  and  each  broad 
ligament,  after  incising  the  mucous  membrane  covering  them 
in  the  vault  of  the  vagina,  was  dissected  free  from  the  bladder 
and  rectal  attachments  and  then  ligated  with  two  strong  liga- 
tures. These  ligatures  were  placed  high  enough  to  include  tho 
uterine  artery,  all  its  Ijranchcs,  and  all  of  tho  contents  of  the 
base  of  each  broad  ligament.  The  ligatures  were  cut  short 
after  they  were  tied,  the  mucous  membrane  of  the  vagina  was 
reunited  with  a  running  catgut  ligature,  and  the  vagina  jxicked 
with  iodoform  gauze.  The  round  ligaments  wore  then  short- 
ened and  the  uterus  left  in  a  position  of  anteversion.  Three 
days  later  tho  gauze  was  removed  from  the  vagina,  an  anti- 
septic douche  was  given  and  a  Smith-Hodge  pessary  was  in- 
serted. The  antiseptic  douches  were  then  continued  daily. 
The  first  menstruation  was  duo  four  days  after  tho  operation. 
It  did  not  appear.  The  second  menstruation  also  failed  to 
appear,  notwithstanding  the  fact  that  menstruation  had  ordi- 
narily been  exhaustive. 

One  of  the  wounds   caused   in    the   operation    for 
shortening  the  round  ligament  suppurated,  and  obliged 


107 


the  i)atient  to  remain  in  the  hospital  until  the  latter 
part  of  January.  Dizziness  was  complained  of  about 
the  time  when  the  menstruation  was  due.  This  symp- 
tom continued  with  different  degrees  of  severity  for 
some  time,  gradually  disappearing.  February  13, 
three  months  after  the  operation,  the  first  flow  ap- 
peared. The  patient  writes:  "First  menstruation 
came  on  the  13th  of  this  month,  without  pain,  but 
quite  profuse  for  first  two  days.  Since  then  has  con- 
tinued, including  to-day  (the  18th).  Discharge  light." 

March  19,  1894,  the  patient  reports:  ''Am  feeling 
fairly  well  this  month.  Had  pain  in  back  with  last 
menstruation,  which  commenced  March  13.  First 
three  days  quite  profuse;  last  four  days  very  little 
No  dizziness  this  month."  Aj^ril  18,  she  writes: 
"  Menstruation  came  on  four  days  in  advance  of 
schedule  time;  continued  one  week.  Am  in  fairly 
good  health." 

December  14,  1895,  two  years  after  the  operation,  the 
husband  writes  that  his  wife  suffers  considerably  with 
vertigo,  especially  severe  immediately  before  menstru- 
ation. •'  The  operation  performed  by  you  has  in  a 
measure  been  successful,  as  the  menstrual  discharge 
is  much  less  than  before  the  oi^eration  and  the  womb 
is  in  much  better  position." 

March  26,  1895,  the  husband  writes:  "  Her  men- 
struation is  not  i^rof  use  and  she  has  less  pain;  her 
general  health  about  the  same"  (as  in  her  last  letter). 
"  I  think  the  riding  of  the  bicycle  improves  her  gen- 
eral health  and  strengthens  her  in  those  parts  wherein 
she  is  weak." 

Cases. — Mrs.  Z.,  Muscatine,  Iowa.  About  35  years  of  age. 
No  children.  Multiple  fibroid  of  the  uterus  approximating  in 
size  a  four  months'  pregnancy.  Hemorrhage  profuse,  followed 
foi  a  week  by  excruciating  pain.  Patient  became  extremely 
exsanguinated  at  each  menstrual  period.  Frequently  the  flow- 
ing would  last  for  two  weeks.  The  uterus  had  been  curetted. 
Electricity  failed  to  control  the  hemorrhage  and  only  |)ar- 
tially  modified  the  pain  The  irregularity  of  the  uterine 
canal  undoubtedly  accounted  for  the  failure  of  the  electricity. 
Nov.  28,  1893,  the  patient  submitted  to  my  operation  for  liga- 
tion of  the  broad  ligament.  The  tumor  was  developed  more  to  the 


108 


left  side  into  the  left  broad  ligament.  I  succeeded  in  separating 
the  broad  ligament  for  a  height  of  two  inches.  On  the  right  side 
a  large  double  ligature  was  employed,  while  on  the  left  side  first 
a  double  and  finally  a  second  one  higher  and  farther  away  from 
the  uterus  was  applied.  The  ligatures  were  cut  short,  the  vagi- 
nal vault  closed  with  catgut  and  the  vagina  packed  with  iodo- 
form drain.  The  first  menstruation  was  due  three  days  follow- 
ing the  operation.  A  slight  watery  discharge  occurred  instead 
of  blood.  Two  days  following  the  operation  the  patient  com- 
plained of  pain  similar  to  that  which  ordinarily  occurred 
after  menstruation.  Feb.  1, 1894,  the  patient's  husband  writes  : 
"  She  commenced  her  menstruation  Januaj-y  25,  and  it  was 
continued  until  to-day,  February  1,  one  day  less  than  last  time. 
Had  one  day  of  some  pain  ;  not  bad.  She  is  getting  stronger 
and  can  get  around  the  house  without  being  very  tired,  although 
she  has  not  yet  ventured  out."  February  26,  the  report  is: 
"Mrs.  Z.  was  sick  this  time  six  days,  the  same  as  last  time. 
Had  considerable  pain  two  days  which  was  very  severe,  the 
same  as  she  complained  of  before  the  operation.  She  is  get- 
ting along  very  nicely.  She  is  now  able  to  go  out,  and  takes  a 
walk  every  day. ' '  March  28,  the  -husband  writes :  "I  am 
ready  to  make  another  report,  but  not  as  good  a  one  as  I  would 
like.  Mrs.  Z.  was  sick  on  time  and  the  flow  was  very  little 
compared  to  what  it  has  been,  iasting  but  three  days,  but  she 
had  a  great  deal  of  pain  -some  before  she  was  sick,  and  it  was 
quite  bad  for  two  days  after  the  menstruation.  .  .  .  Every- 
thing seems  to  be  working  very  well  if  she  could  only  get  rid 
of  that  pain."  April,  menstruation  still  decreasing  in  quan- 
tity ;  the  pain  decreasing.  "  There  was  one  day  of  pain,"  the 
husband  writes,  "  and  the  flow  amounted  to  but  very  little." 
May  6,  he  writes :  "Mrs.  Z.  has  been  feeling  splendidly  all 
this  last  month.  Last  week  was  her  time  to  be  sick  again. 
The  flow  did  not  amount  to  anything,  just  enough  to  show. 
.  ,  .  In  regard  to  her  general  health,  it  is  excellent.  Eats 
well,  sleeps  well  and  goes  out  every  day  the  same  as  other 
women.  Has  gained  her  natural  amount  of  flesh  and  a  little 
more,"  I  examined  the  patient  May  19.  The  uterus  was  re- 
duced in  size  one-half.     Patient  in  perfect  health. 

March  13,  1896,  two  years  and  four  months  after 
this  woman's  operation,  I  received  the  following 
report  from  her:  "  Since  the  operation  I  have  gained 
twenty  pounds  or  a  little  more  up  to  date.  My  men- 
struation period  is  abtjut  one-half  the  time  and  amount 
it  was  before  the  operation.  The  pain  is  very  much 
less  than  I  had  before  the  operation,  but  it  has  not 
left  me  altogether.  ...  I  have  the  strength  of 
the  average  woman  now,  while  before  the  operati(jn  I 


109 


was  comi^elled  to  be  in  bed  over  half  the  time.  Be- 
tween my  menstruations  I  enjoy  as  good  health  as 
any  one  could  ask.     .     .     ." 

Case  9. — Mrs.  C,  aged  41,  a  resident  of  Iowa,  consulted  me 
for  a  bleeding  painful  fibroid  of  the  uterus  in  May,  189i.  The 
tumor  was  interstitial,  uniform  in  contour,  enlarging  the  ute- 
rus to  the  size  of  a  four  months'  pregnancy.  The  hemorrhage 
at  menstruation  was  profuse  and  lasted  six  or  eight  days  at  a 
time.  The  menstrual  periods  were  accompanied  with  consid- 
erable uterine  contraction  pains.  The  patient  complained  of  a 
great  deal  of  heaviness  in  the  pelvis  and  pains  caused  by  the 
pressure  of  the  tumor.  The  patient  was  weak,  rather  exsan- 
guinated and  nervous.  I  concluded  that  the  case  was  a  suit- 
able one  for  my  operation.  The  operation  was  done  May  19, 
1894.  The  lower  portion  of  the  uterus  was  so  large  and  filled 
the  pelvis  so  completely  that  it  was  with  a  great  deal  of  diffi- 
culty that  I  accomplished  the  satisfactory  ligation  of  both 
broad  ligaments.  However,  when  the  operation  was  finished 
I  was  well  satisfied  that  both  uterine  arteries  had  been  thor- 
oughly shut  off. 

The  patient  improved  from  the  first.  There  have 
been  no  more  hemorrhages.  I  have  examined  the 
patient  two  or  three  times  since  the  operation,  once 
v/ithin  six  months.  The  tumor  has  decreased  in  size, 
but  has  not  disappeared.  The  pains  and  pressure 
symptoms  are  much  better.  The  woman  is  apparently 
a  healthy  woman  and  does  very  much  as  other  healthy 
women.  In  reply  to  my  letter  of  inquiry  she  said 
March  12,  1896,  one  year  and  six  months  after  her 
operation:  "  Since  the  operation  I  have  had  but  few 
hemorrhages,  while  previous  to  that  I  had  them  very 
frequently.  I  am  now  quite  regular,  though  I  never 
go  to  my  full  time — about  three  weeks.  I  have  less 
pain,  but  the  heaviness  still  remains.  I  am  better  in 
health  and  strength  than  before  the  operation." 

Judging  from  my  other  cases  I  expect  this  woman 
to  gradually  recover.  My  fear  was,  when  I  adopted 
this  operation,  that  collateral  circulation  would  speed- 
ily overcome  the  result  of  ligating  of  the  blood  sup- 
ply. Experience,  however,  shows  that  the  results  of 
the  operation  are  greater  the  farther  away  from  the 
operation  we  get. 

Case  10. — Mrs.  S..  aged  35,  a  resident  of  the  central  portion  of 


110 

the  State,  came  to  the  Woman  s  Hospital  in  August,  1894,  to 
consult  me  about  an  interstitial  libroid.  She  had  borne  no  chil- 
dren. The  uterus  was  large,  regular  in  contour,  hard  and  about 
four  by  six  inches  in  diameter.  It  was  freely  movable  in  the 
pelvis.  The  woman  gave  a  history  of  severe  monthly  hemor- 
rhages which  lasted  anywhere  from  six  days  to  two  weeks  at  a 
time.  Accompanying  the  flooding  were  severe  contraction 
pains.  The  woman  was  bloodless,  pale,  weak  and  extremely 
nervous.     In  all  other  respects  she  was  normal 

I  did  my  operation  on  the  case  in  August,  1894,  with  the 
assistance  of  the  house  staff  of  the  Woman's  Hospital.  It  was 
easily  performed  on  account  of  the  movability  of  the  tumor 
and  the  looseness  of  the  broad  ligaments. 

September,  1891,  the  patient  wrote:  ''It  is  now  six  weeks 
since  I  have  menstruated.  The  pains  are  not  any  better 
My  bladder  trouble  (pressure)  is  much  relieved."  October, 
1894;  "  I  have  menstruated  since  my  last  letter.  The  quan- 
tity and  length  of  time  was  small.  Had  a  good  deal  of  pain 
the  first  two  days." 

November  13,  1894.  ' '  Menstruations  three  weeks  apart.  I 
flowed  more  than  usual." 

December  17,  1894.     "Pains  some  less.     My  changes  came  ' 
at  the  correct  date,  but  was  greater  in  quantity  than  it  should 
have  been  " 

January  29,  1895.  "I  flow  a  great  deal  more  than  I  think 
I  ought.  I  have  to  change  my  napkins  six  or  seven  times  a 
a  day." 

March  25,  1895.  "I  was  a  little  better  my  sick  week  this 
month.  The  flowing  did  not  last  so  long  as  it  did  before  my 
operation,  but  more  than  is  right.  My  pains  are  gradually 
improving." 

May  27,  1895.  "I  flowed  very  freely  and  had  a  great  deal 
of  pain  this  month." 

Cane  11.— Mrs.  Y.,  the  wife  of  a  very  intelligent  physician  of 
Indiana,  consulted  me  in  November,  1894.  She  had  an  inter- 
stitial fibroid  aVjout  the  size  of  a  four  months'  pregnancy.  She 
was  43  years  of  age.  I  operated  on  her  Nov.  7,  1894.  Both 
broad  ligaments  were  tied,  so  as  to  include  two-thirds  of  their 
bulk.  This  occluded  the  uterine  arteries  on  lioth  sides  with  all 
their  anomalous  branches.  I  have  seen  this  patient  several 
times  since  her  operation  and  the  uterus  is  gradually  lessening 
in  size  and  the  x^atient's  symptoms  are  subsiding.  I  expect 
this  case  to  jjrove  successful  with  a  little  more  time.  In  reply 
to  a  request  from  me  for  a  statement  ot  xji'ogress,  the  husband 
writes  March  12,  1894,  a  year  and  four  months  after  the  oi)era- 
tion,  as  follows  :  "My  Dear  Doctor  :  -  In  reply  to  yours  of  yes- 
terday, I  have  to  say  that  my  wife,  on  whom  you  operated  Nov. 
7.  1894,  is  doing  very  well  as  far  as  the  fibroid  is  concerned.  It 
has  decreased  in  size  some;,  not  a  great  deal.  The  menstrual 
flow  on    two  occasions  was  quite  profuse,   but  the  last  two 


Ill 


periods  have  been  very  scanty  only  lasting  three  days,  and  only 
using  one  or  two  napkins  in  a  day,  whereas  before  the  opera- 
tion she  used  eight  and  ten  each  day  for  four  or  five  days.  She 
suffers  very  little  pain,  in  fact  none  for  the  last  month.  Before 
her  operation  she  suffered  constantly.  Her  general  health  has 
greatly  improved,  and  she  has  gained  ten  pounds  in  flesh,  is 
much  more  cheerful,  and  in  fact  improved  in  every  way.  .  . 
My  wife  is  now  past  45  years  of  age,  and  I  l^elieve  if  the  tumor 
does  not  increase  in  size  until  after  the  menopause,  she  will 
entirely  recover." 

Case  12. — Miss  V.,  single,  age  40,  consulted  me  in  November, 
1894,  on  account  of  a  painful  bleeding  fibroid.  She  was  de- 
pleted to  an  unusual  state,  and  her  nervous  system  was  a 
wreck.  She  had  an  interstitial  fibroid  with  the  canal  of  the 
uterus  measuring  four  inches  in  depth.  The  uterus  measured 
approximatelv  three  by  six  inches  in  diameter.  The  organ  was 
movable.  Hemorrhage  occurred  only  at  regular  menstruation 
periods.  At  this  time  it  lasted  a  week  or  ten  days  and  was  very 
profuse.  Accompanying  the  flow  was  great  prostration  of  the 
patient  and  also  most  excruciating  pelvic  i^ressure  symptoms. 
This  condition  of  affairs  had  been  going  on  for  months  until  the 
patient  from  blood  drain  and  harassment  of  pain  had  been 
brought  to  a  deplorable  state  of  health. 

December  5,  1894, 1  ligated  the  base  of  both  broad  ligaments. 
The  operation  was  accomplished  with  ease  because  the  uterus 
was  movable  and  the  broad  ligaments  loose.  The  patient 
recovered  nicely  from  the  operation.  The  next  two  or  three 
menstruations  were  much  more  normal,  the  quantity  of  How 
being  very  small  and  the  pain  scarcely  perceptible.  The 
woman  was  placed  on  tonics  and  urged  in  every  way  to  increase 
her  blood  supply.  Her  nervous  system  reacted  slowly.  Her 
menstruations  later  became  more  profuse  and  was  accompanied 
on  several  occasions  by  quite  severe  pain.  While  but  a  short 
time  has  elapsed  since  the  operation  the  patient  is  gradually 
improving. 

March  l2,  1896,  one  year  and  three  months  after  the  opera- 
tion, she  writes:  "The  amount  of  menstrual  flow  averages 
about  one-half  the  amount  it  was  before  the  operation.  Have 
gained  a  little  in  fiesh.  Have  considerable  pain.  Still  have 
nerves  although  under  better  control  than  formerly." 

This  patient  has  improved  in  many  ways.  Dur- 
ing lier  intra-menstrual  periods  she  is  compara- 
tively well  and  is  able  to  go  about  and  to  do 
more  work  than  she  should  attempt,  whereas  pre- 
vious to  her  oijeration  she  was  unable  to  do  much. 
While  she  had  been  neglected  for  a  long  time 
and  her  health  had  reached  a  low  ebb,  I  can  not 
but  believe  that  she  will  gradually  improve  as  a  direct 


112 


result  of  the  diminished  flow.  Her  tumor  decreased 
in  the  first  four  weeks  fully  one-third.  It  has  not 
increased  perceptibly  to  the  patient  since  she  left  my 
care. 

Case  13. — Miss  B.,  age  26,  consulted  me  in  January,  1895,  for 
a  bleeding  intramural  fibroid.  The  uterus  was  about  five 
inches  long  and  had  a  canal  three  and  three-quarter  inches  in 
depth.  The  canal  was  a  little  irregular.  In  the  fundus  of  the 
uterus  could  be  felt  two  distinct  centers  of  development,  one 
on  the  anterior  surface  about  two  and  one-half  inches  in  diam- 
eter, and  projecting  from  the  main  body  of  the  uterus  one  and 
one-half  inches.  It  was  hard  and  had  the  unmistakable  firm 
consistency  of  a  fibroid  mass.  On  the  posterior  surface  of  the 
fundus  at  its  junction  with  the  neck  was  a  second  center  pro- 
jecting from  the  uterus  about  one  and  a  half  inches.  This 
mass  was  irregular  and  was  fully  two  inches  in  diameter.  The 
symptoms  which  brought  this  patient  to  me  were  prolonged  and 
exhaustive  hemorrhages  and  uterine  pains.  The  lady  is  a 
vocalist  of  unusual  talent  and  these  symptoms  interfered  seri- 
ously with  her  profession.  The  case  was  a  typical  one  for  hys- 
terectomy, especially  as  the  left  ovary  was  enlarged  and  cystic, 
but  as  that  would  involve  the  removal  of  the  ovaries  the  patient 
objected  to  this  because  of  the  popular  but  unfounded  fear 
that  removal  of  the  ovaries  impairs  the  voice.  I  therefore 
decided  to  perform  my  operation  on  the  case.  When  the 
patient  was  under  the  anesthetic  I  confirmed  absolutely  by 
bimanual  manipulation  my  diagnosis  as  given  above.  Febru- 
ary 1,  1895,  I  operated  on  this  patient.  She  left  the  hospital  in 
two  weeks.  She  did  not  have  an  unfavorable  symptom.  Men- 
struation practically  ceased  from  the  date  of  the  operation. 
There  was  but  the  slightest  show  each  month.  No  pain  what- 
ever. In  less  than  a  month  she  was  able  to  attend  to  her  pro- 
fessional duties  and  was  stronger  than  she  had  ever  been.  G^his 
fjerfect  condition  of  affairs  continued  until  aVjout  Dec.  8,  1895, 
ten  months  after  her  operation.  At  this  time  I  was  called  be- 
cause of  a  sudden  attack  of  severe  pain  she  had  experienced  in 
the  left  side  of  the  pelvic  region.  The  pain  was  accompanied 
with  profound  prostration  and  shock,  I  diagnosed  ruptured 
cyst  of  the  left  side  and  advised  a  laparotomy.  In  making  my 
examination  I  was  surprised  to  find  a  perfectly  normal  uterus. 
I  performed  laparotorhy  on  this  patient  Dec.  28,  1895,  and 
removed  a  ruptured  ovarian  cystof  the  left  side  and  x^unctured 
a  small  cyst  in  the  ovary  of  the  right  side.  This  gave  mo  an 
opportunity  to  examine  the  uterus  which  I  had  treated  by  my 
operation  a  little  over  ten  months  before.  On  the  anterior  por- 
tion of  the  organ  corresponding  to  the  location  of  the  anterior 
fibroid  described  above  1  found  buried  in  the  wall  and  project- 
ing a  half  inch,  a  fibroid  center  one-half  inch  in  diameter.  On 
the  posterior  surface,  corree ponding  to  the  other  center  which 


113 


I  palpated  at  the  previous  operation,  was  another  center  dis- 
tinct but  even  smaller  than  the  anterior  one.  These  were  both 
exhibited  to  the  house  staff  and  physicians  present  at  the  oper- 
ation. The  behavior  of  this  case  was  most  gratifying  until  the 
complication  of  the  ruptured  cyst  arose.  This  fortunately  gave 
me  an  opportunity  of  examining  by  direct  sight  the  results 
accomplished  by  the  first  operation. 

I  have  no  doubt  but  that  those  two  fibroid  centers 
would  have  been  starved  out  eventually  and  the  case 
actually  cured  without  any  further  interference. 

General  Summary:  Thirteen  cases  operated  on  in 
which  more  than  a  year  has  elapsed  since  the 
operation : 

Case  1. — Age  40.  Operation  Nov.  15,  1892.  Very  large 
bleeding  fibroid.  Present  condition :  Tumor  much  reduced. 
Hemorrhages  ceased.    Patient  well. 

Case  2. — Age  40.  Operation  December,  1892.  Fibroid  inter- 
stitial, size  of  three  months'  pregnancy.  Profusely  hemor- 
rhagic. Present  condition:  Tumor  disappeared.  Absolute 
cure. 

Case  3. — Operation  January,  1893.  Interstitial  bleeding 
fibroid  of  two  years  standing.  Four  months  after  operation. 
Last  report :    Tumor  reduced,  patient  much  improved. 

Case  4. — Age  38.  Operation  January,  1893.  Very  large  ad- 
herent intefstitial  fibroid.  Excessively  hemorrhagic.  Patient 
bed-ridden.  Two  years  afterward  :  Uterus  reduced  almost  to 
normal  size.     Hemorrhage  ceased.     Patient  well  and  strong. 

Cased. — Age  30.  Operation  Jan.  8,  1893.  Interstitial  fibroid 
three  by  five  inches  in  diameter.  Profuse  hemorrhage.  Report 
four  months  after  operation :  Uterus  normal ;  hemorrhage 
ceased. 

Case  6.— Age  36.  Operation  Aug.  2,  1894.  Interstitial 
fibroid.  Profusely  hemorrhagic  and  painful.  Patient  much 
reduced.  Tumor  three  by  five  inches  in  diameter.  Six  months 
after  operation  much  improved.     No  later  report. 

Case  7. — Age  35.  Operation  Nov.  11, 1893. .  Incipient  inter- 
stitial bleeding  fibroid.  Two  years  after  operation  :  Tumor 
reduced  ;  hemorrhage  ceased. 

Case  8. -^ Age  3o.  Operation  Nov.  28,  1893.  Painful,  hem- 
orrhagic interstitial  fibroid,  size  of  four  months'  pregnancy. 
Two  years  and  four  months  after  operation  :  Tumor  much  dim- 
ished  ;  hemorrhage  ceased  ;  pain  less  but  not  entirely  relieved. 

Case  9. — Operation  May  19,  1894.  Interstitial,  xjainful,  hem- 
orrhagic fibroid.  Tumor  size  of  four  months'  pregnancy.  One 
year  and  ten  months  after  oxjeration  :  Tumor  slightly  dimin- 
ished ;  hemorrhage  materially  reduced. 

Case  10. — Age  35.  Operation  August  1894.  Tumor  inter- 
stitial four  by  six  inches  in  diameter.     Hemorrhage  and  pain 


114 


excessive.     Not  much  improved  eight  months  after  operation. 

Case  ii.— Operation  November  7,  1891.  Tumor  interstitial, 
hemorrhagic,  painful  and  size  of  four  months  pregnancy.  One 
year  and  four  months  after  operation  :  Tumor  decreased  in 
size  and  hemorrhage  ceased. 

Co.se  12. — Operation  Nov,  1894.  Tumor  interstitial,  pro- 
fusely hemorrhagic,  painful,  and  three  by  six  inches  in  diame- 
ter. One  year  and  three  months  after  operation :  Tumor 
reduced  ;  hemorrhage  less  ;  pain  not  improved. 

Case  13.  —Operation  Feb.  1,  1895.  Tumor  intramural, 
two  centers  of  development  two  inches  in  diameter  each.  Pro- 
fusely hemorrhagic  and  excessively  painful ;  hemorrhage  and 
pain  ceased  ;  tumor  nearly  disappeared,  as  demonstrated  by  a 
laparotomy  ten  months  later. 

MINOR  SURGERY  FOR  SUBMUCOUS  FIBROIDS. 

Pedunculated  submucous  fibroids  may  frequently 
be  completely  removed  through  the  dilated  cervix 
without  interfering  materially  with  the  uterus.  Un- 
less the  tendency  to  pedunculate  is  well  established 
however,  and  the  center  of  development  comprising 
the  tumor  is  the  only  center  of  fibroid  development  to 
be  discovered  in  the  walls  of  the  uterus  as  shown  by 
careful  bimanual  palpation,  it  should  be  treated  by 
hysterectomy  either  vaginal  or  abdominal.  An  excep- 
tion to  this  general  rule  would  be  when  a  peduncu- 
lated fibroid  is  discoverable  either  in  the  cavity  of  the 
uterus  or  hanging  from  the  cervix  with  a  long  thin 
pedicle.  In  such  a  case  the  polypus  should  be  care- 
fully removed  from  the  uterus,  even  though  there 
were  other  centers  of  development  to  be  discovered. 
The  uterus  as  a  whole,  here,  could  be  dealt  with  in  a 
later  operation  if  the  removal  of  the  pedunculated  mass 
did  not  sufficiently  relieve  the  symptoms. 

The  removal  of  an  intrauterine  i)edunculated 
fibroid  is  usually  a  simple  procedure.  If  the  pedicle 
is  small  and  long  and  the  tumor  is  in  a  position  where 
it  can  be  easily  reached  with  forceps,  it  may  be 
grasped  in  a  strong  vulsellum  and  the  tumor  twisted 
until  the  X)edicle  is  actually  twisted  in  two.  This  can 
only  be  done  with  thin  pedicles.  If  the  pedicle  is 
broad  the  uterus  should  be  sufficiently  dilated  (the 
patient  under  an  anesthetic)  to  expose  the  i)edicle,  if 


115 


it  is  necessary  to  accomplish  this  the  cervix  may  be 
divided  as  high  as  the  vaginal  junction.  The  mucous 
membrane  of  the  pedicle  should  next  be  cut  in  its 
entire  circumference.  Then  the  remaining  j)ortion  of 
the  pedicle  composed  of  the  blood  vessels,  connective 
and  muscular  tissue  should  be  twisted  in  the  same 
way  that  one  proceeds  to  twist  off  a  small  pedicle.  If 
the  remaining  portion  of  the  pedicle  is  small  it  will 
give  way  by  that  treatment.  If  it  is  rather  large  and 
fleshy,  after  it  has  been  twisted  into  a  small  bulk  it 
may  be  grasped  by  a  strong  pair  of  curved  pedicle 
forceps  and  the  pedicle  severed  with  scissors  or  a 
knife  outside  of  the  forceps.  If  the  pedicle  is  very 
vascular  the  forceps  may  be  left  in  place  for  six  or 
twelve  hours.  If  this  does  not  seem  necessary  the 
forceps  are  removed  and  the  uterus  packed  with  iodo- 
form gauze.  If  the  forceps  are  left  on  the  pedicle, 
gauze  should  be  packed  around  them.  The  forceps 
may  be  removed  in  six  or  twelve  hours  without  dis- 
turbing the  gauze. 

I  do  not  favor  attempting  to  enucleate  a  submucous 
fibroid  of  any  considerable  size  if  its  principal  bulk  is 
buried  in  the  walls  of  the  uterus.  Such  a  procedure 
is  attended  with  considerable  mechanical  difficulty 
because  of  the  position  of  the  tumor  in  the  cavity  of 
the  uterus;  it  is  a  difficult  matter  to  secure  hemosta- 
sis  in  such  a  location  and  finally  one  seldom  reaches 
in  such  a  procedure  more  than  one  of  several  centers 
of  developments  of  the  tumors  which  are  situated  in 
the  uterus.  In  these  cases  a  hysterectomy  is  more 
satisfactory. 

A  cervical  fibroid  developing  toward  the  mucous 
membrane,  if  pedunculated,  should  be  removed  in  the 
same  manner  as  that  described  for  removing  a  pedun- 
culated intrauterine  fibroid.  A  cervical  fibroid  of 
small  size  may  be  enucleated  by  incising  its  capsule, 
grasping  the  tumor  with  a  vulsellum,  and  dissecting 
it  from  its  bed.  The  cavity  may  be  closed  with 
buried  antiseptic  catgut  sutures  or  it  may  be  packed 
with  iodoform  gauze. 


116 


CURETTEMENT. 

In  many  cases  of  hemorrhagic  fibroids  much  of  the 
hemorrhage  and  leucorrhea  is  caused  by  endometritis. 
A  safe  and  oftentimes  beneficial  treatment  for  such 
cases  is  thorough  dilatation  of  the  uterine  canal  and 
curettement  of  its  mucous  membrane.  While  it  will 
not  ordinarily  have  a  direct  curative  effect  it  will  fre- 
quently relieve  disagreeable  symptoms  for  a  long 
period  of  time.  The  dilatation  should  be  gradual 
beginning  with  Goodell's  dilators  and  afterward 
exploring  the  anterior  of  the  uterus  with  the  index 
finger  to  discover  whether  there  are  any  projecting 
masses  into  the  interior  of  the  cavity.  After  thor- 
ough dilatation  with  the  cervix  exposed  and  grasped 
with  small  vulsellum  forceps  in  order  to  steady  the 
whole  organ,  a  sharp  curette  should  be  made  to  trav- 
erse all  portions  of  the  endometrium.  This  should 
be  accompanied  with  some  form  of  antiseptic  in'iga- 
tion.  The  whole  mucous  membrane  should  be  gone 
over  at  least  three  times  with  the  curette,  the  canal 
then  loosely  packed  with  iodoform  gauze,  the  vagina 
filled  with  the  same  and  the  patient  put  to  bed  for 
several  days.  The  gauze  should  be  removed  in  forty- 
eight  hours.  After  that  antiseptic  vaginal  douches 
must  be  given  for  several  days 


LECTURE  VIII. 


REMOVAL  OF  THE  UTERINE  APPENDAGES. 


Battey,  Tait  and  Hegar  independently  conceived, 
performed  and  contributed  to  modem  surgery  the 
operation  of  removal  of  the  uterine  appendages.  In 
1865  Battey  "conceived"  but  did  not  publish  "the 
idea  of  producing  an  artificial  menoj^ause  for  the 
remedy  of  disease."  His  idea  was  published  in  1872. 
Hegar  operated  on  the  first  case  with  the  object  of 
establishing  an  artificial  menopause,  a  few  days  before 
Aug.  1,  1872,  the  memorable  date  of  Tait'g  first  opera- 
tion for  the  same  purpose.  Battey  did  his  first  opera- 
tion just  sixteen  days  later,  or  Aug.  17,  1872  Thus 
the  time  was  ripe  and  three  great  men  of  three  great 
nations,  separated  by  thousands  of  miles,  discovered 
the  fact,  independently  of  each  other,  and  shook  the 
tree  of  progress  which  has  resulted  in  such  an  abun- 
dant harvest. 

The  removal  of  the  appendages  for  the  cure  of 
fibroids  of  the  uterus  is  based  on  the  facts:  1,  that 
removal  of  the  uterine  appendages  eradicates  the  part 
of  the  economy  in  which  resides  the  organ  or  center 
of  menstruation  and  produces  an  artficial  menopause; 
2,  that  removal  of  the  uterine  appendages  accom- 
plishes a  reduction  of  the  direct  blood  supply  to  the 
uterus  and  thereby  produces  atrophy  by  depleting  the 
organ. 

ARTIFICIAL  MENOPAUSE. 

It  is  yet  an  unsettled  question  where  the  exact  seat 


118 


of  control  of  menstruation  is  located.  It  is  not  the 
province  of  this  article  to  enter  into  the  heated  discus- 
sion as  to  whether  this  remarkable  center  lies  in  the 
ovaries  or  whether  it  is  situated  in  the  nerve  structure 
of  the  Fallopian  tubes.  It  is  enough  for  us  to  know 
that  the  menstrual  center,  wherever  it  lies,  is  eradica- 
ted, in  the  maximum  proportion  of  cases,  when  every 
vestige  of  both  ovaries  and  Fallopian  tubes  is 
removed.  It  is  well  that  such  is  the  case,  because  it 
would  be  an  awkward  and  incomplete  operation  which 
would  seek  to  leave  either  the  ovaries  or  the  tubes. 
These  two  organs  have  a  function  which  of  necessity 
is  incomplete  without  both  of  them.  It  would  be 
difficult  to  remove  the  ovaries  without  interfering 
with  the  circulation  and  position  of  the  tube.  It 
would  be  equally  impossible  to  remove  the  tubes 
without  interfering  with  the  circulation  and  function 
of  the  ovaries.  Then,  too,  a  much  more  secure  and 
desirable  pedicle  can  be  obtained  when  both  organs 
are  included  in  a  ligature  than  is  possible  if  but  one 
of  the  organs  is  selected.  Then,  as  the  function  for 
which  each  of  these  small  organs  is  designed  is  depend- 
ent upon  both,  and  the  removal  of  both  is  easier 
and  therefore  safer  than  the  removal  of  one  of  them, 
and  when  we  take  into  consideration  the  liability  of 
either  of  these  organs  to  become  diseased,  if  not 
removed  when  opportunity  permits,  there  seems  to  be 
no  further  reason  why  both  organs  should  not  always 
be  removed  when  it  is  desirable  to  produce  an  artificial 
menopause. 

REDUCTION  OF  BLOOD  SUPPLY  TO  THE  UTERUS. 

In  a  previous  article  we  discussed  the  blood  supply 
to  the  uterus.  We  found  that  the  organ  depended 
upon  two  sets  of  arteries  for  its  nourishment,  the  uter- 
ine arteries  and  the  ovarian  arteries  (Fig.  21).  The 
normal  ovarian  arteries  are  a  trifle  more  than  half  the 
size  of  the  uterine  arteries.  They  supply  the  ovaries, 
the  tubes,  the  fundus  of  the  uterus  and  anastomose 
with  the  uterine  arteries  which  course  along  the  sides 


119 


of  the  uterus  giving  off  frequent  horizontal  branches 
to  the  uterus.  By  referring  to  Fig.  21  it  can  readily  be 
seen  that  the  ovaries  and  tubes  may  be  removed  with- 
out including  the  main  channel  of  the  ovarian  artery. 
Such  a  method  of  operating  would  deprive  the 
removal  of  the  appendages  for  the  cure  of  fibroids 
of  one  of  its  chief  features  of  benefit,  viz.,  the  reduc- 
tion of  blood  supply  to  the  uterus.  For  that  reason 
special  care  should  be  maintained  by  operators  adopt- 
ing this  procedure  to  include  in  all  cases  the  main 
channel  of  the  ovarian  artery  in  their  ligature.     By 


Figure  21. 


tying  this  artery  on  both  sides  the  large  abnormally 
developed  uterus  is  instantly  deprived  of  one-third  of 
its  blood  supply. 

Dr.  Byron  Robinson,  after  witnessing  my  operation 
of  tying  the  broad  ligament  from  the  vagina,  recog- 
nized the  value  of  this  principle  of  cutting  off  blood 
supply  to  fibroid  uteri,  and  afterward  applied  one  of 
the  principles  of  my  operation  through  an  abdominal 
incision,  after  having  first  removed  the  appendages,  by 
tying  the  uterine  artery  as  it  courses  up  the  side  of 
the  uterus  to  join  the  ovarian  artery. 


]20 


INDICATIONS    FOR    REMOVAL    OF    UTERINE    APPENDAGES 

FOR  FIBROIDS. 

But  a  few  years  ago  this  was  the  operation  of  selec- 
tion for  the  relief  of  uterine  fibroids  when  an  operation 
of  the  severity  of  a  laparotomy  was  deemed  a  necessity. 
It  is  seldom  performed  at  present  except  as  an  opera- 
tion of  dernier  ressort,  when  laparatomy  has  been 
instituted  with  the  object  of  removing  the  tumor  and 
uterus  and,  because  of  contraindications,  the  latter 
operation  is  found  inadvisable.  The  reasons  for  this 
change  of  position  are: 

1.  The  operation  of  vaginal  and  abdominal  hyste- 
rectomy has  been  so  perfected  that  in  patients  of  ordi- 
nary strength,  with  tumors  without  severe  comi)lica- 
tions,  the  mortality  of  hysterectomy  is  not  materially 
greater  than  that  of  double  oophorectomy. 

2.  The  operation  of  removal  of  the  appendages  fails 
about  three  times  in  thirteen  recoveries  to  materially 
reduce  the  size  of  the  tumor,  and  fails  in  one  case  in 
thirteen  recoveries  to  produce  an  artificial  menopause ; 
while  hysterectomy  on  the  other  hand  is  absolutely 
sure  of  curing  every  case  of  fibroid  of  the  uterus, 
which  recovers  from  the  operation  both  of  hemor- 
rhage and  tumor. 

This  materially  narrows  the  field  of  this  operation 
which  has  done  more  to  develojj  modern  surgery  than 
any  other  discovery  of  modem  time,  except  the  dis- 
coveries of  Lister.  The  very  enlightenment  which  it 
has  created  helps  to  make  it  obsolete.  The  operation 
now,  in  the  hands  of  expert  abdominal  surgeons,  is 
limited  to  cases :  1,  where  for  some  reason  the  operation 
is  dem}mded  because  of  prejudice  against  sacrificing 
of  the  uterus;  2,  in  cases  where  for  some  good  reason 
quickness  of  time  in  operating  is  desirable;  3,  in 
cases  where  unusual  complications  are  revealed  when 
tlie  abdomen  is  opened  which  make  hysterectomy 
impracticable;  4,  in  cases  of  small  bleeding  tumors  in 
weak  women  who  are  near  the  menopause;  5,  in  cases 
of   small   hemorrhagic   fibroids   in    weak   women   in 


121 

whom  laparotomy  would  not  ordinarily  be  indicated  but 
which,  are  complicated  with  disease  of  the  appendages. 

THE   OPERATION. 

An  abdominal  operation  is  properly  divided  into 
five  parts:  Incision,  removal  of  pathologic  material, 
drainage,  closure  of  incision  and  dressing. 

The  Incision. — After  the  skin  has  been  prepared  as 
described  in  Lecture  VI,  sterilized  towels  have  been 
placed  around  the  field  of  operation,  the  patient  is 
thoroughly  anesthetized  with  ether  and  the  operating 
corps  is  in  its  place;  the  operator  standing  on  the 
left  side  of  the  patient,  with  a  sharp  scalpel  makes  an 
incision  from  above  downward  in  the  median  line, 
from  about  two  inches  below  the  navel  to  two  inches 
above  the  upper  margin  of  the  pubis,  an  incision 
about  three  inches  in  length.  This  incision  should 
be  unhaggled  and  should  extend  in  dej)th  through 
the  skin,  superficial  fasciae,  the  fat  between  the  super- 
ficial fasciae  down  to  the  deep  fasciae  which  immediately 
covers  the  muscles.  In  experienced  hands  but  one 
stroke  of  the  knife  is  necessary  for  this.  If  the  hem- 
orrhage is  but  venous,  sponges  only  are  necessary 
to  keep  the  wound  dry.  If  there  are  any  arterial 
points  of  bleeding  they  are  caught  in  the  points  of 
forceps  by  the  assistant.  The  operator  by  another 
stroke  of  the  knife  incises  the  white  deep  fasciae,  and 
if  this  incision  is  through  the  linea  alba,  the  subperi- 
toneal space  is  entered,  as  will  be  indicated  by  the 
bulging  fat  of  this  space.  If  the  incision  is  to  the 
right  or  left  of  the  line  the  muscular  coat  of  the 
abdominal  wall  will  be  exposed.  The  muscles  are 
then  separated  by  the  handle  of  the  scalpel  in  a  stroke 
from  above  downward  which  brings  into  view  the  sub- 
peritoneal fat.  The  knife  is  carefully  drawn  over  this 
from  above  downward,  and  this  followed  by  a  sweep 
of  the  scalpel  handle  separates  the  fat  and  subperito- 
neal tissue  down  to  the  peritoneum.  The  peritoneum 
is  now  caught  in  two  catch  forceps  which  are  held  up 
and  separated  laterally  so  as  to  present  a  sharp  eleva- 


122 

tion  of  that  membrane.  This  is  carefully  incised 
with  the  knife.  When  the  peritoneum  is  opened 
it  will  be  indicated  by  its  sudden  elevation  in 
consequence  of  the  entrance  of  air.  An  experienced 
operator  will  frequently  open  an  abdomen  carefully 
in  thirty  seconds.  If  it  is  done  well  it  matters  little 
if  it  takes  five  minutes.  It  is  not  necessary  to  seek 
for  the  linea  alba  if  it  does  not  happen  to  lie  directly 
in  the  center  of  the  superficial  incision.  It  is  more 
important  that  the  wound  should  be  direct  and  the 
different  layers  parallel  than  that  the  muscles  should 
not  be  disturbed.  When  the  peritoneum  is  opened 
between  the  forceps  the  index  finger  should  act  as  a 
director  above  and  below  the  opening  and  the  perito- 
neum incised  with  scissors  the  full  length  of  the 
wound,  being  careful  not  to  wound  the  bladder  below. 
Next  attach  the  peritoneal  edges  of  the  wound  at  the 
center  of  the  incision  on  either  side  to  the  deep  fasciae 
with  small  catch  forceps.  This  prevents  peeling  off 
the  peritoneum  from  the  parietes  in  any  subsequent 
manipulations. 

E.Tjdorfdion. — With  the  index  finger  of  the  left 
hand  I  now  make  my  exploration  of  the  abdominal 
viscera  including  the  appendages.  First  the  uterus  is 
sought  as  a  central  landmark.  From  the  uterus  the 
finger  is  first  swept  to  the  left  side  along  the  Fallo- 
pian tube  from  the  horn  of  the  uterus.  Just  below 
the  tube  and  above  the  broad  ligament  is  the  ovary. 
The  opposite  side  is  rapidly  explored  in  the  same 
manner.  The  exploration  takes  into  consideration 
the  size  and  position  of  the  fibroid  uterus,  adhesions, 
the  condition  of  the  appendages,  the  possibility  or 
feasiVjility  of  removing  them  and  any  abnormal  devel- 
opments. 

Ramovdl  of  the  Appendages. — Our  object,  it  must 
be  remembered,  in  the  removal  of  these  organs  must 
be  to  remove  completely  every  vestige  of  ovary  and 
tube  and  the  thorcjugh  ligation  of  the  main  channel  of 
the  ovarian  vessel.  When  the  uterine  tumor  is  not 
large,  or  if  it  has  not  developed  into  the  broad  liga- 


123 


ment  so  as  to  spread  out  its  folds  and  make  it  tense, 
it  is  an  easy  matter  to  ligate  off  the  tube  and  ovary 
with  one  ligature.  This  is  accomplished  by  lifting 
the  tube  and  ovary  with  the  loose  broad  ligament  and 
making  a  pedicle  of  the  infundibulo-pelvic  ligament 
(Fig.  22  a),  the  ovarian  ligament  (6)  and  the  Fallo- 
pian tube  (c).  The  ligature  No.  10  braided  silk  or 
No,  8  antiseptic  catgut  threaded  in  a  round  non-cut- 
ting needle  is  placed  around  the  pedicle,  never 
through  it  except  as  it  ]3enetrates  and  surrounds  a 
portion  of  the  infundibulo-pelvic  (Fig.  22  a)  and  the 
ovarian  (6)  ligaments  in  order  to  prevent  its  slipping 


Figure  22. 

over  the  edge  of  the  stumi^.  If  the  ligature  is  allowed  to 
transfix  the  pedicle  at  any  other  place  than  through 
the  firm  ligamentous  tissues  of  the  two  ligaments 
mentioned,  it  is  liable  to  produce  venous  oozing  into 
the  loose  subperitoneal  tissue  beneath  the  constric- 
tion of  the  pedicle,  resulting  in  small  hematomas 
which  frequently  prove  troublesome.  After  the  liga- 
ture is  placed  the  ovary  and  tube  are  drawn  well  up 
and  the  strand  of  silk  or  catgut  is  tied  firmly,  first 
with  a  double  twist  knot  and  then  two  single  twists 
and  the  ends  cut  short  (Fig.  23).  A  pair  of  snap  for- 
ceps is  then  placed  on  the  pedicle  outside  of  the  liga- 


124 


ture  and  the  pedicle  is  severed  about  one-fourth 
inch  from  the  ligature,  the  stump  cauterized  or  ren- 
dered sterile  with  some  strong  antiseptic,  this  anti- 
seiDtic  removed  by  a  moist  sponge  and  the  pedicle 
dropped. 

If  the  uterus  is  considerably  enlarged  or  if  it  espe- 
cially develops  into  the  broad  ligaments,  it  is  impos- 
sible to  tie  off  the  appendages  of  each  side  with  a 
single  ligature.  This  is  because  the  loose  folds  of  the 
broad  ligaments  of  which  the  pedicle  is  ordinarily 
constructed,   have  been    occupied  by   the    enlarged 


Figure  23. 


fibroid  uterus,  and  the  ovary  and  tube  are  each  flat- 
tened out  on  the  surface  of  the  tumor  and  are  held 
fast  by  the  peritoneum,  which  ordinarily  acts  as  a 
mesentery  to  each,  Fig.  24.  Under  such  a  disposition 
of  affairs  or  any  modification  of  it,  the  ovaries  and 
tubes  should  be  tied  off'  by  first  ligating  the  neck  of 
the  tube  as  near  the  uterus  as  possible  after  anchoring 
the  ligature  by  a  twist  around  the  utero-ovarian  liga- 
ment (Fig.  24  a);  second  by  ligating  the  broad  liga- 
ment outside   the   fimbriated  extremity  of  the  tube 


125 


Figure  25. 


126 


deep  enough  to  include  the  ovarian  artery,  anchoring 
the  ligature  by  a  twist  around  the  infundibulo-pelvio 
ligament  (Fig.  24);  third,  after  removing  the  tube 
and  ovary  the  two  peritoneal  edges  representing  the 
broad  ligament  to  which  the  tube  and  ovary  are 
attached  between  the  two  ligaments  already  placed, 
should  be  united  from  one  pedicle  to  the  other  with  a 
running  stitch  of  fine  antiseptic  catgut.  This  makes 
a  perfect  exsection  of  the  apiDendages,  and  leaves  the 
peritoneum  perfectly  closed  with  no  tension  on  either 
of  the  pedicles  (Fi^.  25). 

DISEASED  APPENDAGES. 

All  cases,  unfortunately,  are  not  typical  like  the 
ones  we  have  described.  We  often  meet  with  dis- 
eased appendages  when  opening  the  abdomen  for  the 
removal  of  these  organs  in  cases  of  fibroids  of  the 
uterus.  A  pyosalpinx,  or  an  ovarian  cyst,  or  abscess 
of  the  ovaries  are  often  encountered.  Almost  invari- 
ably when  these  things  do  exist,  localized  peritonitis 
has  rendered  them  ad.herent  to  surrounding  tissues, 
the  uterus,  omentum,  intestines  or  the  peritoneum  of 
the  broad  ligament. 

When  these  complications  exist,  and  we  have 
decided  upon  the  removal  of  the  appendages  for  the 
treatment  of  the  fibroid,  we  have  before  us  the  prob- 
lem of  enucleation  and  excision  of  the  diseasecl  and 
adherent  organs.  The  enucleation  of  an  enlarged  pyo- 
salpinx, or  an  ovarian  abscess,  or  a  tubal  ovarian  abscess, 
or  adherent  appendages  the  result  of  an  old  peritonitis 
where  pus  is  no  longer  present,  is  accomplished  in  prac- 
tically the  same  way.  When  the  abdomen  is  explored 
the  abnormal  condition  of  affairs  immediately  becomes 
api^arent.  Frequently  there  is  an  inextricable  mass; 
occasionally  the  outlines  of  the  tube  and  ovary  can 
be  traced  and  they  simply  appear  as  enlarged  adher- 
ent semi-fluctuating  cysts;  while  rarely,  the  appen- 
dages, not  materially  changed  from  their  normal  size, 
will  be  firmly  imbedded  and  adherent. 

I  begin  my  enucleation  in  these  cases,  by  passing 


127 


the  index  finger  of  my  left  hand,  with  the  palmar 
surface  directed  forward,  down  behind  the  isthmus  of 
the  tube  just  as  it  is  given  off  from  the  horn  of  the 
uterus,  hugging  closely  the  body  of  the  uterus  until 
I  have  reached  Douglas's  cul-de-sac.  As  a  rule,  at 
this  place  I  will  find  a  line  of  cleavage  as  indicated 
by  the  adhesions  between  the  tube  and  the  uterus  and 
the  ovary,  and  the  intestines  and  omentum  posterior 
to  the  ovary  and  tubes.  This  line  of  cleavage,  which 
as  it  gives  way  feels  like  two  pieces  of  strong  paper 
which  have  been  stuck  together  with  fresh  mucilage 
giving  way  before  pressure  of  the  fingers  between 
them,  can  be  followed  rapidly,  first  with  one  finger, 
then  with  two  or  more,  until  the  whole  adherent  tube 
and  ovary  are  freed  and  lie  ready  to  be  ligated  ofP  in 
the  palm  of  the  hand.  This  is  the  happy  result  in 
the  majority  of  cases. 

In  a  few  cases,  especially  after  long  standing  disease, 
the  adhesions  are  strong  and  well  organized.  Here 
great  care  and  patience  must  be  exercised,  in  order 
not  to  go  into  an  adherent  bowel,  or  to  the  other 
extreme  and  leave  a  portion  of  the  stroma  of  the 
ovary  or  a  portion  of  the  tube  which  may  be  just 
enough  to  prevent  the  menoi^ause  and  thus  make  our 
oj)eration  a  failure.  Here,  when  the  line  of  cleavage 
fails  to  yield  readily,  it  is  well  to  place  the  patient  in 
the  Trendelenburg  position  and  separate  the  adhesions 
after  exposing  them  to  sight.  With  this  precaution 
and  the  exercise  of  considerable  care  in  manipulation 
it  is  seldom  that  one  need  fail  to  accomplish  an 
enucleation. 

When  these  adherent  masses  are  once  dug  from 
their  beds  the  stumps,  after  ligation,  should  be  ren- 
dered perfectly  sterile  by  the  application  of  the  actual 
cautery  or  strong  chemic  antiseptics.  The  parts 
should  then  be  dried,  and  where  it  is  practicable  the 
raw  surfaces  should  be  covered  with  peritoneum. 

Drainmje. — If  there  is  oozing  from  the  raw  sur- 
faces caused  by  the  enucleation,  a  glass  drainage  tube 
should  be  placed   in   the  cul-de-sac   of  Douglas,  the 


128 


lowest  point  of  the  pelvis,  while  the  toilet  of  the  peri- 
toneum is  being  completed  and  the  abdominal  sutures 
are  being  inserted.  Before  the  abdomen  is  closed 
the  tube  should  be  pumped  out  in  order  to  ascertain 
if  there  is  more  blood  oozing  from  the  peritoneal  sur- 
faces than  would  naturally  be  taken  care  of  by  the 
IDeritoneum.  If  more  than  a  couidIc  of  drams  of  pure 
blood  accumulates  in  the  few  minutes  that  are  required 
to  make  the  toilet  and   insert  the   sutures,  the  tube 


Fkjure  26. 

should  be  allowed  to  remain,  and  the  sutures  tied  so 
as  to  enclose  it  snugly.  The  tube  should  not  be 
larger  than  an  ordinary  lead  pencil,  or  about  one- 
quarter  of  an  inch  in  diameter.  It  should  be  long 
enough  to  project  about  one  inch  above  the  wound 
(Fig.  20)  The  abd(jininal  dressings  are  then  placed 
upon   the  wound   around   the   tube  and   secured  by 


129 


sterilized  muslin  bands  which  are  pinned  to  broad 
adhesive  straps  fastened  to  the  sides  of  the  abdomen 
at  some  little  distance  from  the  wound.  Over  the  top  of 
the  tube  is  slipped  a  piece  of  rubber  dam  (Fig,  26  a) 
about  12  inches  square,  the  tube  penetrating  the  cen- 
ter of  the  sheet  rubber.  The  tube  is  then  pumped 
out  with  a  small  glass  syringe  with  a  long  rubber 
nozzle  which  will  reach  to  its  bottom  (Fig.  27).  After 
finally  emptying  the  tube  a  long  narrow  strip  of  ster- 
ilized gauze  is  carried  to  the  bottom  of  it  with  a 
straight  metal  sound,  a  small  amount  of  the  same 
gauze  is  left  as  a  loose  dressing  over  the  end  of  the 
tube,  over  this  is  folded  the  rubber  dam  and  fastened 
with  a  sterilized  safety  pin,  and  over  all  this  is  placed 
a  liberal  dressing  of  sterilized  cotton  and  finally  over 
this  a  snugly   applied  bandage  of  sterilized  cotton. 


Figure  27. 


Now  when  it  becomes  necessary  to  exhaust  the  drain- 
age tube  in  an  hour  or  two  hours,  it  will  not  be  neces- 
sary to  disturb  the  wound  dressing  at  all.  The 
bandage  is  unfastened,  the  layers  of  cotton  j^arted  in 
the  center  and  the  rubber  dam  opened  and  sjDread  out 
on  the  cotton,  the  capillary  drain  of  gauze  removed 
and  the  tube  exhausted  by  means  of  the  syringe,  an- 
other strip  of  gauze  inserted,  the  rubber  dam  refolded 
and  pinned  and  the  external  dressings  readjusted. 

I  go  into  the  detail  of  my  method  of  caring  for  a 
drainage  tube  in  order  to  justify  myself  for  using  it. 
As  understood  by  the  majority  of  good  surgeons,  it  is 
really  a  dangerous  means  of  draining.  But  a  few 
weeks  ago,  in  a  discussion  in  a  prominent  society  on. 
the  subject  of  abdominal  and  pelvic  surgery,  I  heeird 


130 

a  surgeon  of  no  mean  repute  condemn  the  glass  drain 
and  the  suction  pump,  in  unmeasured  terms,  when  by 
his  very  language,  he  demonstrated  his  ignorance  of 
the  whole  matter  by  saying  that  it  was  necessary  to 
uncover  the  abdominal  wound  every  time  that  the 
tube  is  exhausted.  It  is  not  necessary  to  uncover  the 
wound  at  all  to  dress  a  glass  drainage  tube.  It  is  not 
necessary  to  infect  a  glass  drainage  tube  when  uncov- 
ering it  to  exhaust  it  with  the  suction  syringe,  if  the 
one  doing  the  work  is  trained  and  competent.  The 
nurse  should  be  well  trained.  She  should  wash  her 
hands  to  surgical  cleanliness  before  loosening  the 
bandage  or  removing  the  cotton  over  the  end  of  the 
tube.  She  should  rinse  her  hands  in  1  to  1,000  bichlo- 
rid  solution  before  unpinning  the  rubber  dam;  she 
should  again  rinse  them  in  bichlorid  before  removing 
the  capillary  drain;  she  should  take  the  glass  syringe 
with  its  rubber  nozzle  out  of  a  pitcher  of  1  to  1,000 
bichlorid  solution,  rinse  it  quickly  in  sterilized  water, 
rapidly  exhaust  the  tube,  and  eject  the  fluid  into  a 
small  glass  graduate  which  has  just  been  removed  from 
an  antiseptic  solution ;  when  the  tube  is  dry  she  should 
take  the  steel  sound  out  of  a  dish  of  bichlorid  solu- 
tion, a  strip  of  gauze  out  of  a  fresh  supply  from  a 
sterilized  package  and  insert  it  to  the  bottom  of  the 
drainage  tube.  She  should  again  rinse  her  hands  and 
then  rajndly  close  the  tube  and  replace  the  dressings. 
Such  a  procedure  requires  two  minutes  if  done  by  an 
expert  and  intelligent  nurse.  I  will  agree  with  every- 
body that  this  kind  of  drainage  can  not  be  carried 
out  by  an  ordinary  nurse.  But  when  well  attended  to 
it  is  the  most  satisfactory  method  of  keeping  dry  the 
free  abdominal  cavity  that  we  are  as  yet  acquainted 
with. 

CAPILLARY  DRAIN. 

Occasionally  after  extensive  enucleation  of  diseased 
appendages  we  may  be  so  situated  that  we  have  no 
experienced  nurse  to  leave  in  charge  of  a  glass  drain- 
age tube;  at  the  same  time  we  must  drain,  and  must 
drain  in  a  manner  that  the  after-care  of  the  drain  can 


131 


be  attended  to  by  one  of  little  experience.  In  these 
cases  combined  capillary  gauze  and  tubular  drain, 
through  the  Douglas  cul-de-sac,  may  be  resorted  to. 
A  rubber  tube  one- quarter  inch  in  diameter  and  about 
twelve  inches  long,  and  a  quantity  of  sterilized  iodo- 
form gauze  in  eight  inch  strips  cut  the  strong  way  of 
the  gauze  without  knots,  are  selected.  After  insuring 
thorough  cleansing  of  the  vagina  the  operator,  guided 
by  an  assistant's  j&nger  in  the  vagina,  penetrates  the 
posterior  cul-de-sac  into  the  vault  of  the  vagina  with 
a  pair  of  sharp  pointed  scissors.  The  scissor  blades 
are  then  opened  and  between  them  from  above  down- 
ward, on  a  pair  of  forceps,  is  carried  an  end  of  the 
strip  of  gauze  and  the  rubber  tube.  The  assistant 
grasps  these  in  the  vagina  and  makes  gentle  traction 
on  them.  The  operator  then  loosens  his  grasp  and 
catches  the  abdominal  end  of  the  tube  with  a  pair  of 
catch  forceps.  The  tube  is  then  drawn  through  until 
from  two  to  four  inches  of  its  upper  end,  according 
to  the  extent  of  drain  required,  is  left  in  the  abdom- 
inal cavity  Enough  of  the  gauze  is  drawn  through 
to  make  a  loose  packing  for  the  vagina.  A  small  bunch 
of  the  gauze  is  left  in  the  abdomen  in  the  cul-de-sac, 
around  the  end  of  the  rubber  tube.  It  is  closely 
packed  so  that  it  will  remain  in  the  position  in  which 
it  is  first  placed.  The  abdomen  is  then  closed  in  the 
usual  manner.  The  vaginal  end  of  the  drain  is  ar- 
ranged by  cutting  the  tube  off  at  the  vaginal  outlet; 
and  over  the  vulva  and  the  end  of  the  gauze  is  placed 
a  liberal  pad  of  loose  sterilized  dry  strip  gauze.  Orders 
are  given  to  change  this  outer  gauze  as  often  as  it 
becomes  moist.  When  at  the  end  of  twelve  to  twenty- 
four  hours  there  is  little  drain,  a  portion  of  the  gauze 
may  be  withdrawn  from  the  vagina,  and  if  the  drain 
has  been  slight  the  tube  may  be  removed  at  this  time. 
In  twenty-four  hours  longer,  if  the  drain  is  still  small 
or  none  at  all,  the  drain  may  be  completely  removed. 
After  the  gauze  has  been  removed,  a  liberal  vaginal 
drain  of  gauze  may  be  carried  on  the  end  of  a  forceps 
to  the  vault  of  the  vagina.     This  may  be  removed  in 


132 

twenty-four  hours.  After  this  nothing  further  is  re- 
quired but  an  occasional  vaginal  antiseptic  douche. 
If  drainage  is  profuse  after  twenty-four  to  forty-eight 
hours  the  gauze  drain  should  be  withdrawn  more 
slowly. 

Closing  ahdominal  Wound. — I  favor  any  method 
which  will  coapt  all  the  tissues  of  the  abdominal 
wound  in  the  exact  relation  and  to  the  same  extent 
that  they  were  originally.  This  can  be  accomplished 
by  including  all  the  tissues,  skin,  fat,  superficial  and 
deep  fascia,  muscle,  subperitoneal  fascia,  and  peri- 
toneum in  a  row  of  silkworm  gut  sutures  placed  one- 
third  of  an  inch  apart.  If  I  have  some  of  my  own 
specially  prepared  antiseptic  catgut  at  hand,  I  fre- 
quently sew  the  peritoneal  layer  separately  with  a 
running  thread  of  the  gut  and  then  include  the 
remaining  layers  in  the  row  of  silkworm  gut.  This 
is  especially  desirable  if  one  has  a  long  wound  in  a 
hemorrhagic  patient.  It  completely  closes  the  abdom- 
inal cavity  from  any  oozing  from  the  abdominal 
incision.  It  also  obviates  the  necessity  of  the  silk- 
worm gut  sutures  entering  the  peritoneal  cavity, 
thus  removing  the  remote  danger  of  adhesions  of  the 
abdominal  viscera  to  the  points  of  peritoneum  pene- 
trated by  the  stitch,  and  danger  of  septic  material 
gaining  entrance  to  the  peritoneal  cavity  along  the  route 
of  the  stitch,  in  case  of  external  skin  or  mural  sup- 
puration. I  am  careful  to  include  all  the  tissues  of 
my  wound  in  order  that  the  abdominal  walls  after 
incision  will  be  as  thick  at  the  wound  line  as  at  any 
other  position.  If  it  is  not,  there  will  be  a  concavity 
at  this  point  on  the  peritoneal  surface  which  will  act 
as  a  point  of  resistance,  and  which  will  favor  abdom- 
inal x>ressure  on  the  wound  and  from  which  ventral 
hernia  is  more  liable  to  result. 

Before  tying  the  silkworm  gut  sutures,  I  render  the 
wound  aseptic  by  washing  thoroughly  with  1  to  1,000 
bichlorid  solution  (employing  care  that  none  of  the 
jjoison  enters  the  peritoneal  cavity )  and  finally  rinsing 
the    wound   with   sterilized  water.     After  tying  the 


133 


main  sutures  of  the  wound  I  always  put  in  superficial 
stitches  of  fine  silkworm  gut  wherever  they  are 
necessary  in  order  to  insure  coaptation  of  the  skin 
edges. 

Dressings. — Sterilized  iodoform  powder  mixed  with 
boric  acid  is  dusted  over  the  wound.  Loose  steri- 
lized strip  gauze  is  placed  over  the  wound,  and  sev- 
eral inches  around  it,  and  over  this  is  placed  a  dozen 
thicknesses  of  sterilized  sheet  gauze.  This  is  held  in 
place  by  sterilized  muslin  straps  which  are  pinned  to 
broad  bands  of  adhesive  straps  attached  to  the  skin 
on  the  outer  borders  of  the  abdomen.  This  prevents 
the  dressing  from  becoming  displaced  by  any  move- 
ments the  patient  may  make,  and  it  also  supports  the 
wound  and  takes  the  strain  off  the  sutures.  Over  this 
is  placed  an  abundance  of  sterilized  cotton  and  over 
the  cotton  in  turn  is  placed  a  snug  abdominal  bandage 
with  a  perineal  T  to  keep  it  in  place. 

AFTER-TREATMENT. 

For  detail  after-treatment  I  must  refer  the  reader 
to  Lecture  VI. 

Dressing  the  Wound. — The  wound  is  not  disturbed 
until  the  fourth  day  unless  there  are  symptoms 
indicating  that  it  is  not  doing  well,  viz.,  pain,  fever, 
etc.  At  the  end  of  the  fourth  day  the  nurse  uncovers 
the  wound  carefully,  washes  it  thoroughly  with 
alcohol,  and  1  to  2,000  bichlorid  solution  equal  parts, 
with  sterilized  cotton  on  the  end  of  a  dressing 
forceps.  It  is  then  dried  carefully  and  redusted  with 
sterilized  iodoform  and  boracic  acid.  It  is  then  re- 
covered with  fresh  sterile  gauze.  On  the  seventh  day 
the  same  process  is  repeated  and  the  stitches  removed. 
After  that  it  is  washed  off  in  the  same  manner  every 
day  until  it  is  perfectly  well. 

ANALYSIS  OF  CASES. 

I  have  removed  the  appendages  for  bleeding  fibroids 
of  the  uterus  in  ^o  cases.  These  cases  have  all  recov- 
ered from  the  operation.     The  history,  subsequent  to 


lU 


the  operation  of  a  large  per  cent,  of  these  cases,  I  have 
been  unable  to  trace. 

Cases  26,  28,  47,  48,  55,  61,  64,  or  14  per  cent,  con- 
tinued to  menstruate  indefinitely  after  the  operation. 
Their  symptoms  were  so  severe  in  26,  47,  48,  55,  or  6 
per  cent,  of  the  whole  number  that  hysterectomy  was 
afterward  eiiiployed.  In  none  of  these  cases  was 
hysterectomy  found  necessary  because  of  increase  of 
the  growth  of  the  tumor.  In  the  remaining  cases,  so 
far  as  I  have  been  able  to  trace  them,  the  tumors  have 
reduced  in  size,  hemorrhage  has  ceased  and  the 
patients  have  been  materially  benefited  while  in  a 
small  per  cent,  actual  symptomatic  cures  were 
obtained. 


LECTURE  IX, 


VAGINAL    HYSTERECTOMY. 


HISTORICAL. 


Vaginal  hysterectomy  is  closely  associated  in  it 
early  history  with  cancer  of  the  uterus.  Greig  Smith 
says,  that  it  is  probable  that  incision  of  the  uterus  was 
practiced  by  the  ancient  Greeks,  but  it  is  certain  that 
it  was  subsequently  forgotten.  Soranus,  in  his  book 
of  "  Diseases  of  Women,"  who  lived  in  Rome  a  century 
before  Christ,  describes  the  operation  as  a  surgical 
procedure  for  prolapsus.  The  first  authenticated 
description  of  vaginal  hysterectomy  subsequent  to 
this  was  given  by  Berengarius,  of  Bologna,  in  1507. 

In  1560  Andreas  A  Cruce  performed  vaginal  hyste- 
rectomy. J.  Schenck  a  Grafenberg  1617  (Senn) 
relates  a  number  of  cases  in  which  the  uterus  was 
removed  through  the  vagina  in  whole  or  in  part  by 
ignorant  persons  who  had  not  the  faintest  idea  as  to  the 
diff  culty  or  of  the  extent  and  gravity  of  the  operation. 
In  1792  Saumonier  removed  an  inverted  uterus  below 
a  ligature.  Hildanus  1646,  Wrisberg  1785,  Bernhard 
1821  reported  cases  of  accidental  or  unintentional  re- 
moval of  uteri  by  the  vagina  by  careless  midwives  and 
others.  Intentional  removal  of  the  uterus  by  surgeons 
have  been  reported  by  Zwinger,  Vieusse'n,  Baxter, 
Faivre,  Alexander,  Hunter,  Joseph  Clark  and  Jack- 
son.    (Senn.) 

The  real  history  of  vaginal  hysterectomy  begins 
when  it  was  deliberately  planned  and  executed  for  the 
relief  of  definite   pathologic   conditions.     To  J.  M. 


136 


Langenbeck  in  1813  belongs  the  credit  of  opening 
this  page  of  history.  He  removed  the  uterus  by 
enucleation,  using  neither  clamps  nor  ligatures  and 
his  case  recovered  and  lived  many  years.  The  post- 
mortem demonstrated  to  his  incredulous  critics  the 
truth  of  his  claim.  Sauter,  Jan.  28,  1822;  Elias  von 
Siebold,  April  19,  1823;  Holscher,  Feb.  5,  1824; 
Elias  voii  Siebold,  again  July  25,  1825;  Langenbeck, 
again  Aug.  5,  1825;  Recamier,  July  26,  1829;  Lan- 
genbeck, again  Aug.  18,  1829;  Roux,  Sept.  20  and 
Sept.  25,  1830;  Recamier,  again  Jan.  13,  1830;  Blun- 
dell,  Oct.  16,  1830;  Siebold  1831,  Delbach  1839  are 
the  bold  pioneers  who  followed  the  lead  of  Lan- 
genbeck in  Europe.  From  1839  to  the  revival  of 
Czemy  in  1878  there  are  no  records  of  European 
cases.  In  America,  however,  a  few  cases  were  put  on 
record  during  this  long  interval.  Palmer  Dudley 
reports  that  Dr.  John  M.  Esselman,  of  Nashville, 
Tenn.,  in  September,  1834,  removed  an  inverted 
uterus  by  means  of  the  ligature,  his  patient  recover- 
ing. This  same  surgeon  repeated  the  operation  suc- 
cessfully in  August,  1843,  for  an  inverted  uterus 
containing  a  fibroid.  This  is  the  first  vaginal  hysto- 
rectomy  for  fibroids  of  the  uterus  I  find  recorded. 
The  first  vaginal  hysterectomy  for  cancer  deliberately 
undertaken  and  successfully  executed  in  this  country 
was  i^erformed  by  Dr.  Paul  F.  Eve,  of  Augusta,  Ga., 
April  16,  1850.  (Am.  Journal  of  Medical  Science, 
1858.)  Dr.  L.  C.  Lane,  of  San  Francisco,  operated 
for  cancer  Nov.  11,  1878,  and  at  a  later  date  in  the 
same  year  on  a  second  case  for  cancers.  Both  cases 
recovered.  Lane  executed  this  operation  inde])endently 
of  Czemy,  who  revived  the  operatic^n  in  Europe  by 
I^erforming  his  first  ojjeration  April  12,  1878,  or  seven 
months  earlier  than  Lane. 

From  the  revival  of  Czerny  and  Lane,  with  the 
dawn  of  clean  surgery,  the  oi)eration  of  vaginal  hyste- 
rectomy became  a  legitimate  ojieration.  In  less  than 
twenty  yc^ars  it  has  inade  wonderful  strides.  It  lias 
been  performed  thousands  of  times  Vjy  hundreds  of 


137 

operators,  and  has,  undoubtedly,  been  the  means  of 
adding  many  years  to  the  sum  total  of  human  life. 

VAGINAL   HYSTERECTOMY   FOR   FIBROIDS. 

It  is  argued  that  a  patient  suffers  less  real  shock,  on 
an  average,  when  submitted  to  a  vaginal  hysterectomy 
than  when  operated  upon  by  the  abdominal  route. 
The  only  rational  explanation  that  can  be  forwarded 
to  account  for  this  fact  is  that  the  intestines  and  the 
peritoneum  are  not  subjected  to  exjoosure  to  the  air  in 
the  vaginal  route,  nor  are  they  subjected  to  the  hand- 
ling which  they  are  liable  to  receive  in  the  abdominal 
operations.  While  in  our  improved  methods,  the 
abdominal  contents  are  exposed  and  handled  to  a 
small  degree  compared  to  former  times,  at  the  same 
time  we  can  not  help  but  recognize  that  there  is  less 
shock  after  a  perfect  vaginal  hysterectomy  than  after 
an  abdominal  hysterectomy  in  cases  of  like  severity. 
A  vaginal  hysterectomy  avoids  the  abdominal  scar, 
which  so  many  patients  dread  as  a  brand  of  mutila- 
tion which  must  be  carried  through  life  after  all 
abdominal  operations.  Many  patients  I  find  have 
this  wholesome  dread  to  such  a  degree  that  there 
seems  to  be  no  comparison  in  their  minds  between 
the  two  operations.  An  abdominal  operation  con- 
tains all  the  horrors  of  a  most  dreaded  affair,  while  a 
vaginal  operation  with  no  sign  of  mutilation  left,  is 
contemplated  like  a  normal  labor  with  dread  but 
resignation.  An  abdominal  scar,  it  is  true,  will  fre- 
quently become  the  seat  of  considerable  irritation  and 
rarely  the  seat  of  severe  neuralgic  jpains.  There  is 
always,  too,  the  remote  possibility  of  ventral  hernias 
developing  in  an  abdominal  scar.  It  is  also  claiiiied. 
by  not  a  few  operators,  that  safer  and  more  satisfac- 
tory drainage  can  be  obtained,  when  it  is  required, 
through  the  vaginal  route  than  by  the  abdominal. 
However,  as  soon  as  we  undertake  to  do  a  vaginal 
hysterectomy  on  anything  but  the  smallest  kind  of  a 
fibroid,  we  are  hampered  by  the  narrow  limits  in 
which  we  have  to  do  our  work,  and,  therefore,  if  the 


138 

tumor  is  of  considerable  size,  the  extra  time  its  proper 
removal  from  the  vagina  requires,  off- sets  what  is 
gained  by  non-exposure  of  the  abdominal  viscera. 
So  that  the  rational  surgeon  must  discriminate  here, 
as  everywhere  else  in  surgery,  and  select  the  opera- 
tion which  best  suits  the  individual  case.  If  he  has 
a  small  fibroid,  or  a  large  fibroid  with  relaxed  liga- 
ments and  a  large,  roomy  vagina,  he  should  select  the 
lower  route ;  whereas,  if  he  has  a  large  fibroid  high  in 
the  pelvis,  or  a  small  one  with  a  narrow,  contracted 
vagina  and  rigid  tissues  he  should  do  a  laparotomy 
and  remove  the  tumor  from  above. 

Methods. — Vaginal  hysterectomy  for  fibroids  may 
be  divided  into  two  grand  divisions:  1,  removal  of 
the  uterus  and  its  fibroid  masses  as  a  whole  without 
division,  or  vaginal  hysterectomy  proper;  2,  removal 
of  the  uterus  and  its  accompanying  fibroid  develop- 
ment in  piecemeal  or  morcellement. 

1.    VAGINAL  HYSTERECTOMY  PROPER. 

Indications.  —  Vaginal  hysterectomy  proper  for 
fibroids  must  of  necessity  include  only  the  smallest 
tumors,  or  at  best  fibroid  uteri  with  long,  slender  sub- 
peritoneal projections.  The  operation  is  often  the 
ideal  method  of  treating  small  multii)le  fibroids,  which 
are  so  frequently  the  seat  of  severe  uterine  i)ain  and 
excessive  hemorrhage.  Fibroids  of  considerable  size 
may  frequently  be  treated  by  vaginal  hysterectomy, 
when  the  uterus  is  low  in  the  pelvis  and  the  vagina  is 
large  and  the  tissues  loose.  It  is  an  easy  matter  to 
turn  a  complete  vaginal  hysterectomy  for  fibroids  into 
a  morcellement  should  any  unlooked  for  enlargement 
manifest  itself. 

TECHNIQUE  OF  VAGINAL  HYSTERECTOMY  PROPER. 

The  patient  should  be  prepared  with  the  same  care 
and  manner  that  I  have  described  in  Lecture  VI  on 
prepanitory  treatment  for  laparotomy.  Special  care 
should  be  maintained  to  rencler  the  vaginal  tract  and 
external  genitalia  aseptic.      The  patient    should  be 


139 


anesthetized  with  ether.  She  should  be  placed  in  the 
exaggerated  lithotomy  position  with  the  limbs  sup- 
ported by  some  mechanical  device  which  will  hold 
them  firm  and  for  any  required  length  of  time.  Oth- 
erwise, they  should  be  supported  by  strong  skilled 
assistants  on  either  side,  who  will  also  hold  the  vaginal 
retractors.  Immediately  before  the  operation  begins 
a  nurse  or  a  third  assistant  should  thoroughly  scrub 
the  external  genitalia  and  the  vagina  with  green  soap. 
This  should  be  thoroughly  rinsed  off,  and  the  parts 
should  be  thoroughly  washed  with  95  per  cent,  alco- 
hol and  finally  rubbed  with  1  to  1,000  bichlorid  of 
mercury  and  then  douched  off  with  sterilized  water. 
Moist  sterilized  towels  are  placed  around  the  field  of 
operation.  The  operator  takes  a  seat  at  the  foot  of 
the  table  on  a  small  stool.  At  his  right  are  his  instru- 
ments with  the  surgical  nurse  to  do  his  bidding,  At 
his  left  is  the  nurse  who  superintends  the  irrigator  of 
sterilized  water  and  handles  the  sponges. 

Operation. — Two  small  vaginal  retractors,  with  short 
broad  blades,  are  introduced  and  held  by  the  assis- 
tants so  as  to  retract  the  anterior  and  the  posterior 
vaginal  walls  and  expose  the  cervix  uteri.  The  cervix 
is  grasped  by  a  light  pair  of  vulsellum  forceps  with 
four  teeth,  the  uterus  rapidly  dilated  by  first  intro- 
ducing a  small  dilator  and  then  a  large  strong  one, 
until  its  interior  can  be  reached  and  thoroughly 
explored  with  a  sharp  curette.  The  uterine  cavity  is 
thoroughly  curetted  and  then  rendered  aseptic  by  wash- 
ing out  with  a  solution  of  1  to  100  bichlorid  of  mercury. 
It  is  then  loosely  filled  with  sterilized  gauze.  Through 
the  cervix,  by  means  of  a  curved  needle,  is  passed  a 
strong  double  handling  string  of  braided  silk,  and 
this  is  tied  over  the  os  uteri  in  such  a  w^ay  as  to  close 
the  canal.  The  vulsellum  forceps  are  now  removed 
and  the  strong  silk  ligature  is  henceforth  employed  as 
a  means  of  handling  the  uterus.  The  uterus  is  now 
drawn  well  down  by  making  strong  tractions  and  the 
cervix  drawn  back  so  as  to  expose  the  anterior  utero- 
vaginal fold.     With   a   curved   scissors   the   mucous 


140 


membrane  of  the  vagina  at  its  attachment  to  the 
uterus  anteriorly  is  penetrated  and  the  incisions  car- 
ried to  the  right  and  to  the  left  following  the  utero- 
vaginal junction,  until  the  incisions  meet  posteriorly 
and  the  uterus  is  completely  severed  from  the  vault 
of  the  vagina  (Fig.  27).    The  assistant  now  grasps  the 


Figure  27. 

handling  string  and  makes  downward  and  backward 
traction,  while  the  operator  with  the  index  fingers  of 
both  hands  carefully  seimrates  the  bladder  from  the 
anterior  surface  of  the  uterus.  If  there  are  any  firm 
bands  connecting  the  two  organs,  they  should  be  sev- 
ered with  scissors  near  their  uterine  attachment,  always 


141 


keeping  the  point  of  the  scissors  against  the  firm 
uterine  tissue.  As  soon  as  the  utero-vesical  fold  of 
the  peritoneum  is  reached  with  the  fingers  the  two 
fingers  should  be  separated  laterally,  so  as  to  detach 
the  bladder  from  the  anterior  surface  of  the  broad 
ligament,  and  also  for  the  purpose  of  pushing  the 
ureters,  which  pass  under  the  broad  ligaments  near 
the  cervix,  well  to  the  sides  of  the  pelvis. 

The  assistants  now  draw  the  cervix  forward  and  the 
operator  separates  the  uterus  from  its  posterior 
attachments  and  the  two  fingers  penetrate  through 
the  peritoneum  into  Douglas'  cul-de-sac.  The  fingers 
are  then  separated  laterally  tearing  the  peritoneum  in 
that  direction.  A  large  dry  gauze  sponge,  with  a 
string  attached,  is  pushed  through  this  opening  and 
si^read  out  above  the  uterus.  The  broad  ligaments 
and  the  appendages  are  then  rapidly  examined.  The 
peritoneum  in  front  of  the  uterus  between  it  and  the 
bladder  is  now  torn  through  and  the  broad  ligaments 
are  the  only  attachments  left  between  the  uterus  and 
the  patient.  If  the  uterus  is  not  too  large  and  the 
broad  ligaments  are  loose  and  the  vagina  large,  one 
pair  of  strong  forceps  will  secure  each  broad  ligament. 
The  uterus  is  drawn  well  down  and  the  operator  slips 
his  index  finger  of  the  left  hand  behind  the  left  broad 
ligament  and  crowds  the  appendages  toward  the 
uterus  until  he  can  hook  the  finger  over  the  ligament 
outside  of  the  appendages.  With  the  uterus  held 
well  down  and  steadied  by  one  of  the  assistants,  the 
other  assistant  holding  the  bladder  well  out  of  reach 
by  a  long  narrow  bladed  retractor,  the  operator  with 
his  right  hand  slides  a  strong  pair  of  Byford's  clamp 
forceps  (Fig.  28)  over  the  broad  ligament,  the  poste- 
rior blade  following  the  lead  of  the  index  finger, 
which  is  still  holding  the  ligament,  until  they  include 
its  whole  width,  and  project  half  an  inch  beyond  its 
upper  edge  when  they  are  closed  and  locked.  The 
jaws  of  the  forceps  should  be  examined  carefully  to 
see  that  they  include  all  the  tissues  necessary,  and 
that  it  compresses  all  portions  sufficiently.     The  locks 


142 


of  the  forceps  should  be  securely  tied.  With  the 
index  finger  guiding  the  scissors,  the  clamped  liga- 
ment is  now  severed  close  to  the  uterus.  If  the 
uterus  is  not  too  large  and  the  right  broad  ligament 
is  long  the  organ  can  be  delivered  as  the  next  step 
and  when  delivered  the  right  broad  ligament  may  be 
clamped  with  ease  outside  of  the  vulva.  If  this  is 
possible  the  clamp  should  be  applied  outside  of  the 
appendages  and  the  uterus  cut  away.  Frequently, 
however,  the  uterus  can  not  be  delivered  until  the 
other  clamp  is  ai)plied  and  the  ligaments  severed. 
Under  such  circumstances  the  forceps  should  be  care- 
fully aj)plied  exactly  like  the  first  one  and  the  liga- 
ments divided  with  the  scissors  from  below  upward 


Figure  28. 


while  the  assistant  makes  slight  traction  on  the  uterus 
until  the  organ  is  free,  when  it  is  delivered.  The 
broad  ligament  forceps  are  carefully  examined  now, 
to  be  sure  that  each  is  doing  all  the  work  required  of 
it,  viz.,  including  the  whole  ligament  in  its  .grasp  and 
firmly  comjjressing  every  portion  sufficiently  tight  to 
maintain  hemostasis.  Should  any  portion  need  rein- 
forcing, a  small  pair  of  straight  hemostatic  forcejjs 
may  be  ajjplied  to  the  projecting  free  end  of  the  sev- 
ered tissue.  Occasionally  it  is  not  practicable  nor 
safe  to  include  the  whole  broad  ligament  in  one  pair 
of  forceps  because  of  its  width  and  bulk,  while  again 
it  may  be  difficult  to  j)lace  the  forceps  on  the  whole 


143 


ligament  at  once,  because  of  a  too  narrow  vagina 
or  a  highly  situated  uterus  with  short  ligaments. 
Here  the  bulky  base  of  each  broad  ligament 
should  be  clamped  first,  with  short  stout  catch 
forceps  and  the  ligaments  severed  up  to  within 
a  short  distance  of  the  forceps'  bite.  The  uterus  then 
can  be  drawn  down  and  the  remaining  portion  of  the 
broad  ligaments  can  be  secured  in  one  pair  of  forceps 
on  each  side.  The  last  forceps  are  placed  on  the 
uterine  side  of  the  first  pair.  All  the  forceps  are  now 
held  by  the  assistants  to  their  respective  sides  of  the 
vagina  with  their  handles  separated  in  such  a  manner 
as  to  act  as  lateral  retractors.  The  sponge  is  removed 
from  the  pelvis  and  the  toilet  of  the  peritoneal  cavity 
is  made  by  drying  it  with  sponges  on  holders.  The 
posterior  retractor  is  now  inserted  and  the  operator 
seeks  the  edge  of  the  peritoneum  which  covers  the 
bladder,  grasps  it  with  a  catch  forceps  and  draws  it 
down  and  with  a  running  stitch  of  antiseptic  catgut 
attaches  it  to  the  upper  end  of  the  anterior  vaginal 
wall.  An  anterior  retractor  is  now  inserted  and  the 
edge  of  the  peritoneum  covering  the  rectum  is  attached 
to  the  upjper  end  of  tliQ  XDOsterior  vaginal  wall  in  the 
same  manner.  This  insures  hemostasis  of  the  anterior 
and  posterior  vaginal  edges,  and  covers  an  otherwise 
uncovered  gap  of  connective  tissue  space. 

Drainage. — The  forceps  are  widely  sej^arated,  two 
narrow  retractors  hold  open  the  vagina  anteriorly  and 
posteriorly,  a  square  piece  of  sterilized  iodoform  gauze 
two  feet  wide  is  placed  with  its  center  over  the  vulva, 
and  with  a  large  pair  of  dressing  forceps  its  folded 
center  is  carried  well  into  the  vagina  beyond  the  ends 
of  the  forceps,  so  as  to  form  a  bag.  It  is  then  loosely 
packed  with  strips  of  sterilized  iodoform  gauze  and 
the  edges  of  the  filled  bag  are  left  projecting  several 
inches  from  the  vulva.  It  is  folded  over  the  vulva. 
The  handles  of  the  clamp  forceps  are  wrapped  in 
gauze.  A  liberal  supply  of  absorbent  cotton  is  placed 
over  and  around  the  forceps  and  over  the  perineum 
and  vulva,  and  all  held  in  place  by  three  small  perin- 


144 


eal  bandages,  one  passing  between  the  handles  of  the 
forceps  and  the  other  two  outside  of  the  forceps 
handles. 

VAGINAL    HYSTERECTOMY   BY   MORCELLEMENT. 

Indicdfions. — Vaginal  hysterectomy  by  morcelle- 
ment  may  be  done  for  fibroids  of  considerable  size,  the 
limit  of  maximum  size  on  which  the  operation  may 
be  safely  undertaken  depending  on  the  skill  and  expe- 
rience of  the  particular  operator.  The  writer  does  not 
favor  the  ojDeration  where  the  uterus  is  too  large  to 
deliver  easily  after  bisecting,  preferring  to  undertake 
such  cases  by  the  abdominal  route.  The  operation  is 
now  performed  every  day,  however,  by  an  increasing 
number  of  skillful  men  on  fibroids  of  every  size,  even 
on  tumors  reaching  well  above  the  umbilicus. 

Polk,  a  firm  believer  in  morcellement  for  fibroids, 
lays  down  the  following  indications:  1.  Whenever 
the  mass  is  largely  within  the  pelvis,  especially  if  it 
is  fixed  therein  by  adhesions.  2.  Whenever  the  mass 
is  soft  and,  therefore,  compressable  as  in  myoma  and 
fibrocystoma.  3.  In  all  other  cases  where  we  have  a 
patient  in  good  condition  ^ose  pelvis  is  shallow, 
where  the  vaginal  canal  is  roomy,  and  in  whom  the 
evidence  of  a  pyosalpinx  above  the  j^elvis  brim  are 
absent.  Pean,  Segmond,  Richelot,  Jacobs,  Henrotin 
and  others  do  not  make  suppurating  appendages  a 
contraindication  to  this  method  of  operating. 

TECHNIQUE. 

Crises  with  Uterus  only  Double  its  Natural  Size. — 
In  these  cases  the  technique  is  very  similar  to  that  for 
simple  vaginal  hysterectomy,  with  the  exception  that 
the  uterus  is  bisected  with  an  antero- j)osterior  incision. 

Step  1:  The  vagina  is  severed  close  to  the  cervix, 
as  in  ordinary  vaginal  hysterectomy,  and  the  uterus 
denuded  until  the  posterior  and  anterior  cul-de-sacs 
are  opened. 

Step  2 :  Grasp  the  anterior  lip  of  the  cervix  on  either 
side  with  strong  bullet  forceps  or  two  well  embedded 


145 


handling  strings,  and  making  strong  traction  split  the 
anterior  wall  of  the  uterus  with  strong  scissors  with 
the  posterior  blade  guided  by  the  uterine  canal 
(Fig.  29).  When  the  scissors  have  reached  the  limit 
of  exposure  of  the  uterus  the  edge  of  the  split  uterus 
at  the  highest  point  of  the  incision  should  be  grasped 
by  the  bullet  forcei^s,  and  with  this  new  grasp  the 
uterus  should  be  drawTi  down  still  farther  and  the 


Figure  29. 


splitting  process  continued.  When  the  uterus  is 
usually  movable  or  the  broad  ligaments  unusually 
long,  sometimes  at  this  point  the  partially  split  uterus 
is  completely  anteverted  and  the  fundus  is  delivered. 
As  a  rule,  however,  whenever  it  is  necessary  to  split 
the  uterus  at  all  in  order  to  remove  it,  the  bisecting 
must  be  carried  to  completion. 


146 


Step  3:  When  the  bisected  uterus  is  well  drawn 
down,  the  increased  movability  of  the  organ  in  conse- 
quence of  being  in  two  pieces  enables  one  to  clamp 
the  broad  ligaments  with  one,  or  at  most  two  forceps, 
and  the  respective  halves  are  removed.  After  one 
side  has  been  cut  away  it  is  an  easy  matter  to  clamp 
and  remove  the  opposite  half. 

Step  4:  Finish  operation  and  apply  drainage  as  in 
simple  vaginal  hysterectomy. 

Variations  of  Procedure. — If  it  is  convenient  it 
is  often  better  to  attempt  to  clamp  the  broad  liga- 
ments immediately  after  opening  the  two  cul-de-sacs, 
in  order  to  save  the  patient  as  much  blood  as  possible. 
When  it  is  not  possible  to  clamp  the  whole  broad  lig- 
ament, the  base  of  the  ligaments  with  the  uterine  arte- 
ries may  be  secured.  As  a  preliminary  every  precau- 
tion should  be  observed  to  render  the  cavity  of  the 
uterus  aseptic. 

Cases  icith  Uterus  More  than  Double  Its  Normal 
Size. — In  these  cases  the  uterus  must  be  removed  by 
piecemeal.  In  order  to  accomplish  this  so  as  not  to 
make  a  horrible  failure,  a  thoroughly  systematic 
course  must  be  observed  by  one  skilled  in  the  details 
of  pelvic  surgery  and  surgical  emergencies.  No  two 
cases  are  alike.  Consequently  no  two  operations  are 
ever  identical. 

Step  1:  Circular  incisions  around  the  cervix, 
after  first  grasping  the  anterior  and  the  posterior  lip 
of  the  cervix  with  strong  forceps.  The  uterus  is 
denuded  anteriorly  and  posteriorly  and  the  posterior 
cul-de-sac  is  opened.  An  attemj^t  is  then  made  to 
enter  the  anterior  cul-de-sac. 

Step  2:  Clamp  forceps  are  now  placed  on  the  base 
of  each  broad  ligament  high  enough  to  include  the 
uterine  artery  and  its  branches,  and  the  ligaments  are 
cut  nearly  as  high  as  the  point  of  the  clamp. 

Step  3:  The  cervix  is  split  into  halves  by  a  lateral 
incision  on  the  line  of  the  uterine  canal  with  strong 
scissors  or  a  knife  (Fig.  30). 

Step  4:  With  the  anterior  lip  well  drawn  down  and 


147 


firmly  held,  the  posterior  lip  is  drawn  well  down  and 
amputated.  The  remaining  stump  of  the  posterior 
half  of  the  uterus  is  firmly  grasped  in  forceps,  keep- 
ing the  uterus  well  down  in  the  field  of  operation. 

Step  5 :  If  the  uterus  is  not  too  large  at  this  point  a 
single  clamp  forceps  may  be  placed  on  the  remaining 
portion  of  the  broad  ligament. 


Figure  30. 


Step  6:  With  hemostasis  well  secured,  from  this 
point  on  the  splitting  of  the  uterus  is  continued  and 
morcellation  is  proceeded  with  by  amputation  of  first 
one-half  or  a  portion  of  a  half  and  then  the  other,  sever- 
ing the  broad  ligaments  by  degrees  until  by  piecemeal 


148 


the  whole  uterus  is  removed.  Care  should  be  main- 
tained to  have  a  secure  hold  of  the  uterus  with  forceps 
at  some  point  besides  the  point  of  amputation  at  all 
times,  in  order  that  it  may  not  slip  out  of  the  field  of 
operation.  As  soon  as  the  uterine  mass  has  been 
reduced  suflBciently  so  that  it  may  be  delivered  it 
should  be  removed.  Care  must  be  exerted  to  secure 
all  large  subperitoneal  masses  which  from  their  situa- 
tion might  by  carelessness  be  accidently  separated 
from  the  tumor  and  escape  beyond  the  reach  of  the 
finger  or  forcej^s.  As  the  morcellement  progresses  a 
finger  in  the  x^osterior  cul-de-sac  from  time  to  time 
learns  facts  of  value  to  the  operator. 

Bemarks. — The  care  of  the  forceps  and  the  care  of 
the  vaginal  and  jDeritoneal  edges,  after  this  modified 
operation,  is  identical  to  that  after  the  simple  opera- 
tion. The  toilet  of  the  operation  field  and  the  drain- 
age is  the  same.  If  adhesions  exist  they  must  be  care- 
fully separated.  If  the  anterior  cul-de-sac  is  elevated 
so  that  it  can  not  be  entered  before  amputation  is 
commenced,  amputation  should  be  proceeded  with  and 
the  uterus  gradually  drawn  down  until  the  cul-de-sao 
can  be  opened. 

Accidents  to  he  avoided. — Wounding  of  the  bladder 
or  intestines  and  clamping  one  or  both  carelessly  are 
accidents  which  must  be  carefully  guarded  against 
in  vaginal  hysterectomy  of  any  kind.  Severing  of 
important  blood  vessels  before  they  are  securely 
clamped  is  another  annoying  accident,  because  of  the 
tendency  of  the  unsecured  blood  vessels  to  retract 
into  the  loose  connective  tissue  of  the  broad  ligament, 
where  they  will  continue  to  bleed  out  of  reach  of 
hemostatic  forceps.  To  avoid  this  accident  great  car© 
should  be  observed  to  securely  clamp  all  tissues  before 
severing,  and  if  there  is  the  slightest  doubt  about  the 
security  of  any  portion  of  the  divided  ligament  after  it 
has  been  cut,  a  second  clamp  should  reinforce  the  first. 
To  avoid  clamping  the  ureters  the  forceps  should  not  be 
applied  to  the  base  of  the  broad  ligament  until  the 
bladder  is  thoroughly    separated   from   its   anterior 


149 

surface,  until  the  finger  can  sweep  between  it  and 
the  broad  ligament  to  the  sides  of  the  pelvis. 
This  insures  the  pushing  of  the  ureters  out  of  the 
reach  of  the  forceps.  This  same  maneuver  insures 
the  integrity  of  the  bladder  also.  If  the  bladder 
is  found  so  adherent  at  any  portion  that  it  is  not 
readily  separated  with  the  finger,  scissors  should  be 
employed  to  dissect  it  from  the  face  of  the  uterus  or 
tumor,  great  care  being  observed  to  avoid  wounding 
the  bladder  with  the  scissors  by  keeping  the  point  of 
that  instrument  against  the  uterus.  By  following  the 
imperative  rule  of  separating  the  bladder  early  and 
keeping  it  out  of  the  field  of  oj)eration  by  the  use  of 
an  anterior  retractor,  it  will  never  be  wounded.  To 
avoid  wounding  the  rectum  the  same  care  should  be 
observed  in  entering  the  posterior  cul-de-sac  as  is 
exerted  in  opening  the  anterior  one.  If  one  carelessly 
opens  this  pouch,  it  is  an  easy  matter  to  strip  the 
peritoneal  covering  of  the  bowel  posterior  to  the  cul- 
de-sac  and  miss  entering  the  peritoneal  cavity  entirely ; 
while  by  ignorantly  pursuing  this  false  track  the  rec- 
tum may  be  penetrated.  To  avoid  this  embarrassing 
predicament  stick  to  the  uterus.  If  one  does  strip  off 
a  portion  of  the  uterine  peritoneum  it  will  do  no  harm 
and  the  rectum  is  safe. 

USE   OF   LIGATURES   FOR   VAGINAL   HYSTERECTOMY. 

By  some  operators  ligatures  are  emjDloyed  for  secur- 
ing hemostasis  instead  of  clamps.  In  simple,  uncom- 
plicated cases  ligatures  may  be  employed  with  ease. 
In  morcellement,  where  high  and  excessive  manipula- 
tion is  required  the  ligatures  are  impracticable  be- 
cause of  the.  difficulty  of  applying  them,  and  because 
of  the  difficulty  of  preventing  them  from  becoming 
loosened  by  the  subsequent  manipulation  of  the  parts. 
When  ligatures  are  employed  they  prolong  the  con- 
valescence if  they  are  left  long  and  allowed  to  ulcerate 
away.  The  time  required  for  the  accomplishment  of 
that  act  is  from  twelve  to  forty  days.  During  all  this 
time  it  requires  great  diligence  on  the  part  of  the 


150 


attendant  to  prevent  infecting  of  the  ligatures;  in  fact, 
it  is  seldom  prevented.  An  offensive  vaginal  dis- 
charge bears  evidence  of  the  fact,  until  the  ligatures 
are  finally  discharged.  If  ligatures  are  employed 
and  cut  short,  with  the  idea  of  burying  them,  it  fre- 
quently happens  that  they  become  infected,  even 
when  the  greatest  care  is  observed  to  preserv^e  cleanli- 
ness. The  reason  for  this  is  the  necessity  for  drain- 
age in  almost  all  of  these  cases.  The  method  of 
drainage  makes  the  wound  practically  an  open  one. 
Hence  the  danger  of  some  portion  of  the  otherwise 
buried  ligatures  becoming  infected.  Once  infected 
long  months  of  pus  discharge  from  vaginal  fistula  is 
the  sequel.  This  is  all  avoided  when  hemostasis  is 
secured  by  strong  forceps,  because  the  means  of  hemos- 
tasis (the  forceps)  are  removed  in  forty-eight  hours, 
and  nothing  is  left  of  a  foreign  nature  which  may  be- 
come infected. 

AFTER-TREATMENT   OF    VAGINAL    HYSTERECTOMY   WITH 

CLAMPS. 

Shock  is  treated  on  the  lines  laid  down  in  Lecture 
VI.  I  must,  also,  refer  the  reader  to  that  Lecture 
for  the  detail  treatment  of  the  bowels  and  care  of 
the  patient  as  regards  drink,  diet,  etc.  The  bladder 
is  emptied  every  eight  hours  with  a  catheter  until 
the  forceps  and  the  first  drainage  is  removed.  The 
catheter  should  be  employed  oftener  if  it  is  neces- 
sary. The  nurse  employs  an  aseptic  glass  catheter 
with  a  small  nozzle  which  will  run  the  urine  off  into 
a  bottle.  The  urethra  is  carefully  exposed  before  the 
catheter  is  introduced  and  thoroughly  wiped  off  with 
a  saturated  solution  of  boracic  acid. 

Forceps. — The  locks  of  the  forceps  are  carefully 
tied  at  the  time  they  are  put  on  to  avoid  accidental 
unclasping  of  their  blades.  The  handles  are  kept 
covered  with  sterilized  gauze.  If  it  gets  soiled  at  any 
time  it  is  changed.  At  the  end  of  twenty-four  hours 
all  but  the  principal  forceps  are  removed.  The  string 
securing  the  lock  is  cut,  the  lock  unfastened  carefully, 


151 


the  blades  opened  enough  to  loosen  their  grasp  on  the 
tissues  and  then  they  are  carefully  removed.  At  the 
end  of  forty-eight  hours  the  main  forceps  are  removed 
in  the  same  manner.  If  the  tissues  in  any  particular 
case  showed  unusual  tendencies  to  bleed  at  the  time 
of  the  operation  I  allow  the  forceps  to  remain  twenty- 
four  hours  longer.  When  the  large  forceps  are  re- 
moved they  should  be  opened  widely  before  an  attempt 
is  made  to  withdraw  them,  and  then  they  should  be 
brought  out  with  a  backward  motion  in  order  to  avoid 
catching  the  tissues  with  the  projection  on  the  pos- 
terior blade. 

Di^essing. — If  the  external  portion  of  the  drain  be- 
comes soiled  with  accidental  discharges  of  urine  or 
excessive  drain  fluid  it  should  be  removed  and  replaced 
with  a  new^  external  pad  of  loose  sterilized  gauze  as 
often  as  is  necessary.  Twelve  hours  after  the  last 
forceps  are  removed  about  one-third  of  the  external 
gauze  drain  should  be  removed  and  a  fresh  pad  of 
gauze  placed  over  the  vulva.  In  twenty- four  hours 
another  third  should  be  extracted,  and  in  twenty-four 
hours  more,  or  sixty  hours  after  the  last  forceps  are  re- 
moved, all  of  the  balance  should  be  taken  out.  When 
the  last  gauze  is  removed  an  external  irrigation  should 
be  employed  of  1  to  5,000  bichlorid  solution  followed 
by  a  plain  water  irrigation.  A  small  sterilized  iodo- 
form drain  should  now  be  carried  carefully  about  three 
inches  into  the  vagina  on  a  strong  pair  of  dressing 
forceps,  and  the  end  of  the  drain  allowed  to  protrude 
from  the  vagina.  Over  this  is  placed  an  antiseptic 
absorbent  pad.  In  twenty-four  hours  this  drain  is 
removed  and  then  eighty-four  hours  after  the  last  for- 
ceps are  removed,  and  the  peritoneum  has  had  ample 
time  to  close,  the  first  vaginal  douche  is  given. 

Douches. — This  douche  must  be  given  with  extreme 
care  by  a  nurse  who  understands  all  the  responsibility 
she  is  entrusted  with.  The  douche  point  must  be 
made  of  glass,  bulbous,  with  openings  directed  only 
at  right  angles  to  it.  The  patient  should  be  placed 
on  her  back  at  the  edge  of  a  bed  with  feet  supported 


152 


on  two  chairs.  A  Kelly  pad  should  be  under  her 
buttocks.  The  reservoir  containing  sterilized  water 
of  a  temperature  of  105  should  be  placed  but  eighteen 
inches  above  the  patient's  hips,  in  order  to  have  but 
slight  iDressure.  The  nurse  after  thoroughly  preparing 
her  hands,  inserts  two  fingers  into  the  vagina  about 
two  and  one-half  inches,  and  between  the  lingers  ex- 
tending to  within  one-half  inch  of  their  extremities 
is  inserted  the  douche  point.  The  water  is  turned  on 
with  every  x^recaution  employed  to  secure  immediate 
and  free  return  current.  The  douche  is  repeated  in 
this  way,  the  nurse  introducing  the  fingers  and  douche 
point  a  little  further  each  time  until  the  vault  of  the 
vagina  is  reached, every  twelve  hours  until  the  sixth  day 
from  the  removal  of  the  forceps,  when  1  to  5,000  bi- 
chlorid  of  mercury  solution  may  be  substituted  for  the 
I)lain  douche,  always  following  the  bichlorid  douche  by 
a  plain  one.  It  must  be  obvious  why  I  insist  on  the 
great  care  in  employing  this  douche.  The  peritoneal 
cavity  is  expected  to  close  in  a  few  hours  after  the 
gauze  is  removed.  Frequently,  there  is  no  doubt,  it 
is  closed  off  a  few  hours  after  the  operation  is  finished. 
Notwithstanding  this  tendency  to  early  closure  of  the 
peritoneal  cavity,  carelessness  in  employing  the  first 
few  douches,  if  free  return  stream  is  not  provided  and 
great  pressure  employed  by  placing  the  reservoir  too 
high,  might  result  in  breaking  up  the  union  of  the 
tissues  and  fill  the  abdominal  cavity  with  the  fluids 
and  debris  of  the  vaginal  tract.  After  each  douche 
the  vulva  should  be  covered  with  an  antiseptic  pad. 
After  each  urination  or  movement  of  the  bowels  the 
external  parts  should  be  douched  otf  with  sterilized 
w.iter  and  the  antiseptic  dressing  renewed. 

(jfettuifj  Up. — Patients  manifest  a  desire  to  get  up 
earlier  aft(^r  vaginal  hysterectcjmy  than  after  abdominal 
operations.  There  is  less  prolonged  reaction  in  the  way 
of  nervous  exhaustion  as  there  is  less  immediate  shock 
with  the  vaginal  o])erati<m.  I  alhjw  my  patients  to 
begin  to  sit  up  on  the  twelfth  to  fifteenth  day.  They 
can  leave  the  hosjjital  from  the  twentieth  day  onward. 


153 


Results. — I  have  performed  vaginal  hysterectomy 
for  uncomplicated  fibroids  of  the  uterus  forty-one 
times;  one  death  resulted  from  the  operation.  At 
least  twenty  of  these  cases  were  performed  with  clamps 
as  the  exclusive  means  of  securing  the  broad  liga- 
ments. In  the  balance  of  cases  ligatures  of  silk  alone 
or  ligatures  reinforced  with  forceps  were  employed. 
The  majority  of  my  cases  were  small  tumors.  In  two 
cases  there  was  a  troublesome  hemorrhage  within 
twelve  hours  after  the  operation,  from  the  vaginal 
edges,  which  was,  however,  easily  controlled  by  apply- 
ing small  catch  forceps  to  the  bleeding  i^oint.  I 
opened  the  bladder  in  one  of  my  early  cases;  it  was 
subsequently  closed  in  a  secondary  oiDeration.  I  have 
never  had  secondary  hemorrhage  or  the  slightest 
oozing  after  removing  the  clamps.  I  have  never  had 
a  vaginal  hernia.  I  have  never  had  a  troublesome 
vaginal  fistula.  In  one  case  wdiere  ligatures  were 
used  and  left  long  they  did  not  come  away  for  nearly 
six  months. 

Dr.  Edward  Garceau  of  Boston,  to  whose  writings 
on  vaginal  hysterectomy  I  am  indebted  in  pre- 
paring this  article,  gave  in  his  excellent  paper  on 
"  Vaginal  Hysterectomy  as  Done  in  France,''  in  the 
American  Journal  of  Obstetrics,  Nov.  3,  1895,  the 
following  table  of  operations  with  their  results,  to 
which  list  I  add  my  own  cases.  A  list  like  the  sub- 
joined can  not  be  said  to  represent  the  average  mor- 
tality of  the  operation  because  it  includes  the  work 
alone  of  the  most  experienced  operators  in  this  line  in 
several  countries.  At  the  same  time  it  must  be  remem- 
bered that  this  represents  pioneer  work  in  a  compar- 
atively new  procedure. 


Operator. 

Cases. 

Deaths, 

Mayer 

Pean 

.    .    .         1       .    .    . 

...    200      ... 

0 

4 

Jacobs  

...      22      ... 

2 

Mangiagalli.    .    . 
De  Ott 

.    .    .        8      .    .    . 
...    100      ... 

0 

0 

Carle 

22 

0 

Calderini  .... 

.    .   .       1      .    .    . 

0 

154 


Bockel 3  0 

Routier 6  ^ 

Richelot 43  i 

F.  H.  Martin il  ■•■ 


447  8- 

This  gives  a  mortality  of  1.7  per  cent. 


LECTURE  X. 


ABDOMINAL   HYSTERECTOMY. 


HISTORY. 

Dr.  Gilman  Kimball  of  Lowell,  Mass.,  was  the  first  to 
deliberately  plan  and  execute  an  abdominal  hysterec- 
tomy for  fibroids  of  the  uterus.  The  operation  was 
performed  in  August,  1853.  On  June  25  of  that  year, 
Dr.  Walter  Burnham  of  the  same  city  removed  a  por- 
tion of  the  uterus  for  this  disease.  Ten  years  later, 
December  19,  1863,  Koeberle  did  his  first  hysterec- 
tomy for  fibroids,  with  external  fixation  of  the  stump 
of  the  uterus.  He  employed  a  metallic  ligature  with  a 
special  device  for  tightening  it.  Pean  soon  followed 
Koeberle  and  supplementing  the  latter's  work  by  the 
free  employment  of  f orci-pressure,  and  by  publishing  a 
systematic  technique,  which  included  the  employment 
of  steel  pedicle  pins  over  the  metallic  ligature  for  main- 
taining the  pedicle  extra-abdominally,  his  name  became 
inseparably  associated  with  hysterectomy  by  the  extra- 
peritoneal method.  Dr.  M.  M.  Latta,  of  Goshen,  Ind., 
completed  an  abdominal  hysterectomy  by  tying  the 
broad  ligaments  in  sections  down  to  vagina  July  6,1876. 
The  elastic  ligature  for  temporary  ligation  was  first 
employed  by  Kleeberg,  of  Odessa,  July,  8,  1878.  In 
August,  1878,  Martin  recommended  the  provisional 
elastic  ligature.  Hegar  about  the  same  time  recom- 
mended the  elastic  ligature  for  permanent  intra- 
abdominal ligation  of  the  pedicle. 

In  the  evolution  of  abdominal  hysterectomy  many 
methods  have  been  adopted  and  at  different  times 


156 

each  have  had  their  advocates.  The  yearnmg  for  per- 
fection has  made  confusion,  owing  to  great  efforts  in 
many  directions.  In  the  early  history  of  the  operation 
the  best  results  came  with  the  extra-peritoneal  method 
of  treating  the  stump.  This  continued  until  the  last 
few  years  when,  with  improved  technique,  greater 
experience,  and  to  avoid  unpleasant  sequela  the  pen- 
dulum is  irresistibly  swinging  toward  the  intra- 
abdominal pedicle.  The.  history  carries  us  through 
the  following  methods:  1,  extra-peritoneal  or  Pean's; 
2,  intra-peritoneal  or  Schroeder's;  3,  complete  hyster- 
ectomy or  Eastman's;  4,  vaginal  fixation  or  By  ford's; 
5,  ligation  of  arteries  outside  of  uterine  tissue  with 
intra-i^eritoneal  stump  or  Stim^Dson-Baer  method. 

1.  Extra-peritoneal  Method. — The  extra-peritoneal 
method  as  originally  carried  out  by  Pean,  consisted 
in  clamj^ing  the  neck  of  the  tumor  with  a  wire  clamp 
or  serre-noeud  including  the  broad  ligaments  with  the 
appendages,  preventing  slipping  of  the  constrictors 
with  pedicle  pins,  excising  of  the  tumor,  fixation 
of  the  pedicle  in  the  lower  angle  of  the  abdominal 
wound,  and  closure  of  the  abdominal  wound  closely 
down  to  the  stump.  Joseph  Price  of  this  country 
has  imjjroved  this  method  until  it  is  well-nigh  perfect. 
His  success  with  it  has  been  phenomenal. 

Hegar  and  Kallenbach  modified  it  by  carefully  secur- 
ing the  pedicle  after  Schroeder's  method  and  uniting 
it  in  the  abdominal  incision  extra-peritoneally  but 
beneath  the  closed  incision. 

Kelly  and  independently  Van  de  Walker  modified  it 
by  making  temporary  fixation,  like  Pean,  until  liability 
to  liemorrhage  had  ceased,  when  the  wire  was  removed 
and  the  x->edicle  allowed  to  contract  into  abdominal 
incision. 

2.  Iiitra-peritoneal  Method. — This,  as  practiced  by 
Schroeder,  consisted  primarily  in  constricting  the 
jjedicle  with  the  Kleeberg  rubber  band,  removing  the 
tumor,  paring  down  the  stumi),  taking  from  its  center 
a  wedge-shaped  piece  of  the  bulky  tissue,  cauterizing 
the    canal,   closing   the   stump   by   strongly   sewing 


157 


together  the  edges  of  the  wedge-shaped  incision  and 
finally  sewing  over  all  the  jjeritoneal  edges.  The 
stitching  of  the  stump  was  intended  to  bo  secure 
enough  so  that  all  subsequent  oozing  was  made  impos- 
sible after  the  final  removal  of  the  rubber  ligature. 
The  iDedicle  was  then  dropped,  as  is  the  pedicle  after 
ordinary  ovariotomy,  and  the  abdomen  closed. 

This  method  was  modified  by  Olshausen,  Charles 
T.  Parkes,  Zweife],  Hofmeier  and  others. 

(a)  Olshausen  modified  by  securing  the  pedicle 
with  a  rubber  ligature,  and  sinking  the  whole  by 
sewing  over  it  the  f)eritoneum. 

(b)  Charles T.  Parkes  modified  it  by  ligating  firmly 
with  strong  silk  and  cauterizing  the  tissues  of  the 
pedicle  to  firm  bone-like  condition  w4th  the  actual 
cautery  over  a  temporary  clamp. 

(c)  Zweifel  tied  the  pedicle  firmly  with  a  strong 
multiple  ligature  of  silk,  securing  it  in  this  manner  in 
several  parts. 

(d)  Marcy  of  Boston,  1881,  secured  an  intra- 
abdominal stump  by  sewing  from  the  outer  edge  of 
one  broad  ligament  to  the  other  with  thirteen  cobbler's 
stitches;  including  in  the  process  ovarian  arteries, 
broad  ligaments,  uterine  arteries  and  the  stump  of  the 
uterus  formed  by  the  cervix  uteri. 

(e)  Hofmeier  carefully  ligated  the  pedicle  in  its  cir- 
cumference without  closing  the  cervical  canal,  and 
closed  its  abdominal  end  by  covering  with  peritoneum. 
Drainage  could  take  place  into  the  vagina  through  the 
patulous  canal. 

(/)  Goffe  and  Albert  independently  employed  treat- 
ment similar  to  Hofmeier's,  with  the  addition  of 
applying  a  capillary  drain  through  the  open  cervix 
into  the  vagina. 

3.  Complete  Removal,  Eastmaifs  methods. 

(a)  In  1888  Dr.  Mary  A.  D.  Jones  removed  the 
entire  uterus,  including  the  cervix,  by  employing  long 
hemostatic  forceps  for  the  lower  portion  of  the  broad 
ligament,  and  severing  the  cervix  from  the  vagina. 

(6)  Joseph  Eastman's  method,  1889:     The  broad 


158 

ligaments  are  tied  off,  including  the  appendages,  the 
vagina  opened  posteriorly  by  elevating  it  by  means  of 
a  special  staff  constructed  for  the  purpose,  which  is 
held  by  an  assistant,  the  vaginal  edges  are  ligated  with 
long  ligatures  which  afterward  serve  to  invert  the 
edges  into  the  vagina,  and  the  cervix  and  stump  are 
progressively  cut  away.  The  iDeritoneum  is  sewed  over 
the  inverted  vaginal  edges^  the  abdominal  wound  is 
closed,  and  the  vagina  packed  with  gauze.  The  mass 
of  the  tumor,  if  cumbersome,  may  be  cut  away,  pre- 
vious to  opening  the  vagina,  by  putting  on  a  tempo- 
rary rubber  ligature. 

(c)  Eastman  in  1884  enucleated  the  stump  without 
first  tying  the  uterine  arteries  by  peeling  the  pedicle 
portion  of  the  uterus  with  a  serrated  gouge,  keeping 
inside  of  the  uterine  arteries  in  their  course  up  the 
side  of  the  uterus. 

4.  Vcujinal  Fixation,  Byford's  Method, — The  broad 
ligaments  are  tied  with  silk  and  severed.  The  cervix 
is  secured  with  provisional  rubber  ligature,  the  tumor 
€ut  away,  the  pedicle  firmly  tied  with  multiple  silk 
ligatures,  left  long,  the  stump  trimmed  and  closed  with 
long  silk  ligatures,  an  opening  made  into  the  vagina 
in  front  of  the  cervix,  the  ligatures  securing  the 
pedicle  carried  through  it  by  traction  on  them,  the 
stump  inverted  into  the  vagina,  the  peritoneum  over 
the  inverted  cervix  closed  by  stitching  the  bladder 
peritoneum  to  that  covering  the  pedicle,  closure  of 
the  abdominal  wound,  and  finally  j)lacing  a  special 
hemostatic  clamp  on  the  inverted  pedicle  in  the 
vagina. 

Meinert,  independently  of  Byford,  suggested  pulling 
the  pedicle  into  the  vagina  through  Douglas's  cul-de- 
sac,  but  is  not  known  to  have  accomplished  it. 

Polk,  of  New  York,  has  removed  the  entire  cervix, 
stitching  the  vaginal  stump  to  the  abdominal  wall. 

Thus  briefly  do  we  get  an  outline  history  of  the 
develoi)ment  of  the  technique  of  this  important  oper- 
ation. Erom  the  beginning  the  struggle  was  in  the 
direction   of    accomplishing  complete  hemostasis  of 


159 

the  pedicle  without  the  necessity  of  invariably  fixing 
it  in  the  abdominal  wall.  It  was  soon  demonstrated 
that  no  XDedicle  comprised  of  cervical  or  uterine  tissue 
could  be  made  bloodless  by  any  amount  of  ligating 
with  non-elastic  ligatures  which  could  not  from  time 
io  time  be  tightened  as  the  tissues  shrunk.  Hence 
with  silk,  steel  or  clamj)  hemostasis  it  was  necessary 
to  fix  the  pedicle  externally  in  order  that  they  might 
be  tightened  in  case  of  necessity.  Elastic  ligatures, 
while  they  accomplished  perfect  hemostasis,  experi- 
ence soon  demonstrated  were  not  safe  ligatures  to  bury, 
because  they  frequently  gave  rise  to  suppuration  when 
the  strangulated  pedicle  was  dropped.  At  last  it 
.seemed  inevitable  that  external  fixation  of  the  pedicle 
was  to  be  the  only  safe  method  of  accomplishing 
abdominal  hysterectomy.  The  displacement  of  the 
tissues  necessary  for  abdominal  fixation  and  its  dis- 
tressing sequelae — bladder  pressure,  painful  cicatrix, 
dragging  pain,  hernise,  depressed  cicatrix,  etc.,  made 
surgeons  slow  to  accept  that  means  as  final,  while  at 
the  same  time  there  seemed  no  other  alternative.  The 
Taginal  fixation  of  Byford's  which  came  in  late  in  the 
race,  solved  many  of  the  difficulties,  and  if  something 
better  had  not  speedily  followed,  it  would  have  become 
the  ideal  method  of  pedicle  fixation.  But  when  the 
struggle  was  at  its  height  the  w^hole  problem  was  sud- 
denly solved  by  the  ap]3lication  of  a  simple  little  prin- 
ciple described  by  Stimson  in  1889  and  i^racticed  by 
■others  and  redescribed  and  emphasized  by  Baer,  of 
Philadelphia,  in  1892.  The  principle  consists  in 
obtaining  hemostasis  of  the  uterine  stum^D  by  ligating 
its  blood  supply  outside  of  the  uterine  tissue  before 
it  reaches  its  substance;  or,  in  other  words,  by  ligating 
the  uterine  arteries  at  either  side  of  the  cervix.  East- 
man had  practically  accomplished  the  same  thing  in 
his  old  operation  of  complete  removal  of  the  uterus 
the  same  year  Stimson  announced  it,  but  none  of  us 
recognized  the  princij^le  involved,  nor  did  he  announce 
with  sufficient  emphasis  why  he  succeeded.  So  Stim- 
son and   Baer  get   the   credit  of  promulgating   and 


160 

establishing  a  great  but  simple  principle,  and  the 
uterus  is  removed  every  day  now,  j^artially  or  wholly, 
and  the  pedicle  di'opx^ed  with  perfect  impunity. 

5.  Ligation  of  Arteries  at  Side  of  the  Uterine 
Tissue  with  Intra-abdominal  Stuwp:  Stiwson-Baer 
Mctliod. — This  method  is  accomplished  by  ligating 
the  ovarian  arteries  with  or  without  the  broad  liga- 
ment, severing  the  broad  ligaments  after  placing  hem- 
ostatic clamps  on  the  uterine  side  down  to  the  uterine 
arteries,  ligation  of  the  uterine  arteries,  severing  the 
uterus  at  the  cervix,  cauterizing  the  cervical  canal, 
trimming  the  cervix,  closing  the  stump  with  catgut  or 
silk,  burying  the  pedicle  with  peritoneum,  closing  the 
broad  ligaments  with  a  running  stitch  of  catgut,  and 
closing  the  abdominal  wall. 

Senn  modifies  this  operation  by  stri]3ping  the  tumor 
of  its  peritoneum  in  front  and  behind  for  three  inches, 
severing  the  tumor  at  its  bottom  so  as  to  leave  the 
peritoneum  like  a  cufp  and  then  fixing  this  cuff  open 
to  the  lower  angle  of  the  abdominal  wall,  draining  it 
with  iodoform  gauze  until  all  danger  of  hemorrhage 
has  ceased,  when  the  gauze  is  removed  and  the  cuff 
closed  by  closing  the  abdominal  wound  by  tying 
sutures  inserted  at  the  time  of  the  operation.  Stim- 
son-Baer  principle  when  thoroughly  carried  out 
makes  Professor  Senn's  precautions  superfluous. 

INDICATIONS    FOR   ABDOMINAL   HYSTERECTOMY  FOR 
UTERINE   FIBROIDS. 

Successful  abdominal  hysterectomy  is  the  only 
absolutely  sure  cure  for  large  fibroids  of  the  uterus. 
Ergot,  electricity,  ligation  of  the  blood  supply  will 
cure  a  certain  percentage,  but  hysterectomy  removes 
at  once  every  vestige  of  the  tumor  and  with  it  the 
uterus  on  which  it  j^ropagates. 

The  operation  of  abdominal  hysterectomy,  in  its 
I)resent  condition  of  perfection,  in  the  hands  of  expe- 
rienced operators  should  be  the  operation  of  selection 
in  all  fibroids  which  can  not  be  removed  by  vaginal 
hysterectomy  when  the  patient  is  in  a  physical  condi- 


161 


tion  which  will  not  jeopardize  her  immediate  recovery 
from  the  operation. 

Multiple  intramural  fibroids  of  every  kind  which 
are  producing  distressing  symptoms  should  be  sub- 
mitted to  hysterectomy  because  there  is  no  absolute 
cure  for  them  by  any  other  means. 

SuhjyeritoneaJ  fibroids  when  from  multiple  develop- 
ments can  only  be  removed  by  abdominal  hysterec- 
tomy; no  other  treatment  will  reach  them. 

Interstitial  fibroids  of  large  size,  of  hemorrhagic 
nature,  if  the  patients  are  in  a  fair  physical  condition, 
should  always  be  treated  by  abdominal  hysterectomy. 

Cystic  fibroids  can  only  be  cured  by  hysterectomy. 
Any  form  of  treatment  less  radical  only  aggravates 
these  cases. 

Suj)purating  fibroids  imperatively  demand  hys- 
terectomy. 

Fibroids  complicated  with  pelvic  suppurations, 
pyosalx^inx,  supi^urating  ovaries  or  appendicitis, 
should  be  removed  at  the  same  time  that  the  pelvis  is 
cleaned  out. 

Large  fibroids  complicated  with  pregnancy  where 
there  is  the  slightest  doubt  of  a  successful  normal 
ending  of  the  condition  of  pregnancy,  demand  abdom- 
inal hysterectomy. 

ABDOMINAL  HYSTERECTOMY — TECHNIQUE. 

Uncomplicated  Case. — The  writer  adopts  the  Stim- 
son-Baer  operation  for  uncomplicated  hysterectomies 
for  any  cause.  The  abdomen  is  opened  with  a  liberal 
incision  which  will  allow  of  easy  delivery  of  the 
tumor.  The  lower  end  of  the  incision  is  carried  well 
down  to  within  an  inch  of  the  symphysis  pubis.  If 
the  bladder  is  unusually  high  the  incision  at  the 
lower  end  need  not  include  the  peritoneum.  The 
tumor  should  next  be  delivered  by  lifting  it  out  with 
the  hand  or  a  strong  joair  of  vulsellum  forceps  fixed 
in  the  fundus  of  the  uterus  or  top  of  the  tumor.  It 
is  very  necessary  that  the  tumor  be  delivered  at  this 
point  in  order  to  continue  the  work  of  removal  intel- 


162 


ligently.  As  soon  as  the  tumor  is  outside  of  the 
abdomen  the  general  peritoneal  cavity  should  be  shut 
off  with  liberal  packs  of  diy  sterilized  gauze.  If  the 
intestines  are  inclined  to  protrude  the  abdominal 
incision  may  be  closed  above  the  pelvis  with  a  tem- 
porary silk  suture.  The  broad  ligaments  are  next 
clamped  with  a  strong  j)air  of  long  jawed  hemostatic 
forceps  far  enough  away  from  the  uterus  so  that 
another  forceps  of  the  same  character  may  be  placed 
between  it  and  the  uterus,  and  low  enough  to  include 
all  the  upper  portion  of  the  broad  ligament  with  the 
ovarian  arteries.  The  broad  ligaments  on  either  side 
are  next  severed  between  the  forceps  to  the  lower 
limit  of  their  bite.  This  frees  the  uterus  well  down 
to  the  cervix  and  the  region  of  the  uterine  arteries. 
The  peritoneum  on  the  anterior  surface  of  the  uterus 
is  severed  at  the  utero-vesical  fold  transversely,  the 
ends  of  the  incision  ending  at  the  two  provisional 
forceps  placed  on  the  uterine  end  of  the  severed 
broad  ligament.  The  cervix  is  then  stripped  of  its 
peritoneum  anteriorly,  care  being  exercised  to  sepa- 
rate the  bladder  from  it,  thoroughly.  After  the 
uterus  is  well  denuded  of  its  peritoneum  belov/  the 
point  marked  off  by  the  knife,  and  the  bladder  is  well 
separated  a  gauze  sponge  of  small  size  may  be  placed 
temporarily  on  the  denuded  surface.  It  is  well  at 
this  point,  too,  to  peel  off'  a  small  flap  of  peritoneum 
from  the  posterior  surface  of  the  lower  jjortion  of  the 
body  and  cervix,  beginning  an  inch  above  the  i)oint 
at  which  the  stump  will  be  made,  and  denuding  to  a 
point  just  below  it.  The  uterus  is  now  drawn  well  to 
one  side,  retractors  placed  on  the  opposite  side  and  the 
uterine  artery  is  secured  by  placing  around  it  a  strong 
silk  or  antiseptic  catgut  ligature.  The  artery  is 
securely  tied  and  the  ligature  left  long.  A  pair  of 
artery  forceps  is  placed  on  the  tissue  secured  by  the 
ligature  between  it  and  the  cervix,  and  the  tissue  sev- 
ered between  the  forceps  and  the  uterus.  The  oppo- 
site side  is  treated  in  the  same  manner.  The  uterus 
ifl  now  removed  by  severing  it  at  its  neck.     The  inci- 


163 


sion  is  begun  about  an  inch  above  the  vaginal  attach- 
ment anteriorly  and  posteriorly  and  carried  toward  the 
uterine  canal  in  such  a  way  as  to  leave  the  uterine 
stump,  a  hollow  wedge  with  the  apex  at  the  cervical 
canal,  and  the  sides  of  the  wedge  the  anterior  and 
posterior  surfaces  of  the  stump,  which  when  approx- 
imated, form  flaps  which  completely  shut  off  the 
cervical  canal  and  the  cavity  of  the  pedicle  from  the 
abdominal  cavity.  The  uterus  can  be  severed  from 
the  cervix  best  with  a  knife.     As  soon  as  the  flaps 


Figure  28. 

are  begun  posteriorly  and  anteriorly  the  stump  should 
be  steadied  and  controlled  by  securing  these  flaps  in 
strong  lock  forceps.  (Fig.  28.)  As  the  uterus  is  sev- 
ered great  care  should  be  exerted  not  to  infect  the 
abdominal  cavity  with  any  septic  matter  which  may 
be  in  the  uterine  canal,  and  the  cervical  canal  must 
be  immediately  cauterized  or  otherwise  rendered 
sterile. 

The  stump  is  now  closed  by  uniting  the  two  flaps  with 
inversion  sutures  of  antiseptic  catgut.     The  simplest 


164 


and  most  satisfactory  method  of  suturing  for  this  pur- 
pose in  my  opinion  is  the  one  employed  by  Prof.  A. 
H.  Ferguson,  Fig.  29.  The  stitch  is  an  interrupted 
one  as  shown  in  the  drawing,  and  completely  closes 
the  flaps  without  i^enetratmg  their  cut  surfaces.  Prof. 
Ferguson  uses  the  stitch  in  bowel  surgery  to  take  the 
place  of  the  Lembert  suture.  When  the  pedicle  is 
closed  it  is  dropped. 

At  this  point  the  upper  portion  of  the  broad  liga- 


Fjoure  29. 


Method  of  suturing  the  pedicle  in  hysterectomy;  a,  pedicle  unclosed; 
b,  pedicle  and  method  of  introducinf?  inversion  stitch;  c,  the  comx)leted 
pedicle. 

ment  upon  which  the  provisional  hemostatic  forceps 
were  jjlaced  must  be  cared  ior.  It  contains  the  ova- 
rian artery  as  it  passes  along  the  broad  ligament  par- 
allel to  the  infundiV)ulo-pelvic  ligament  which  should 
be  securely  tied.  Next  if  the  pedicle  of  the  broad  liga- 
ment is  long  enough  so  that  it  can  be  easily  included  in 
the  ligature  left  long  after  ligating  the  uterine  artery 


165 


without  undue  tension,  it  should  be  so  included,  secur- 
ing the  ligature  from  slipping  by  taking  a  turn  around 
thfe  infundibulo-pelvic  ligament.  When  the  ligament 
is  in  place  ready  to  be  tied  the  forceps  should  be  re- 
moved from  it  and  the  ligature  firmly  tied,  with  a 
treble  knot,  and  forceps  attached  to  the  pedicle  out- 
side of  the  ligature.  The  opposite  side  is  treated  in 
the  same  manner. 

Everything  is  now  finished  about  the  pedicle  except 
closing  the  peritoneum  over  the  stump.  This  is 
accomiplished  by  stitching  together  with  a  running 
suture  of  antiseptic  catgut  the  two  edges  of  the  peri- 
toneum which  was  stripped  off  the  anterior  and  pos- 
terior surfaces  of  the  uterus  before  amputating  the 
uterus.  When  this  is  done  the  pelvic  peritoneum  is 
perfectly  closed,  and  as  soon  as  the  toilet  of  the  cavity 
is  completed,  the  abominal  wound  should  be  sutured, 
the  dressings  applied  and  the  patient  put  to  bed. 

Remarks. — The  Trendelenburg  position  may  usu- 
ally be  used  with  advantage  immediately  after  the 
uterus  is  amputated  in  order  to  ex^Dose  the  bottom  of 
the  pelvis.  Some  operators  place  their  patients  in  this 
position  from  the  beginning  of  the  operation.  Drain- 
age is  not  necessary  after  a  normal  case. 

COMPLICATED    CASES, 

Unfortunately  in  the  surgery  of  fibroid  tumors 
uncomplicated  cases  are  not  the  rule.  The  most  com- 
mon anomalies  are  the  following:  1,  pedunculated 
tumors;  2,  tumors  developed  into  the  broad  ligament; 
3,  interstitial  tumors  involving  the  cervix;  4,  tumors 
complicated  with  diseased  appendages;  5,  sui^purating 
fibroids;  6,  tumors  complicated  with  pregnancy;  7, 
extra-peritoneal  fibroids. 

1.  Pedunculated  Tu)nors. — Tumors  of  varying 
sizes  with  small  pedicles  are  occasionally  found  grow- 
ing from  some  portion  of  the  uterus.  If  they  repre- 
sent a  distinct  tumor  and  the  uterus  is  not  involved 
with  separate  or  other  centers  of  fibroid  development, 
and  the  appendages   are  not  involved,  the  operator 


166 

sliould  seek  to  remove  the  tumor  without  interfering 
with  the  uterus  proper.  In  order  to  accomplish  the 
removal  of  these  pedunculated  masses,  and  secure  a 
pedicle  which  may  be  safely  dropped  a  definite  line  of 
procedure  should  be  followed.  If  the  tumor  is  only 
partially  pedunculated  so  that  a  portion  of  its  bulk  is 
buried  in  the  uterus  necessitating  enucleation,  I  pre- 
fer to  remove  the  uterus,  as  I  consider  that  the  only 
absolutely  safe  procedure  under  the  circumstances.  If 
the  tumor,  however,  is  pedunculated,  so  that  a  pedicle 
of  peritoneum,  connective  tissue,  and  the  blood  vessels 
feeding  the  tumor,  without  tumor  tissue  or  uterine  tis- 
sue, can  be  secured  after  its  removal,  I  do  not  hesitate 
to  ligate  and  drop  the  pedicle  any  more  than  I  would 
hesitate  to  drop  the  pedicle  of  an  ovarian  cyst. 

Method:  The  tumor  is  delivered.  A  pair  of  strong 
hemostatic  forceps  is  clamj)ed  on  the  pedicle  between 
the  tumor  and  uterus,  unless  the  tumor  encroaches 
upon  the  pedicle  too  much  to  make  a  clamp  effective 
after  the  growth  has  been  enucleated,  when  instead  of 
a  clamp  a  provisional  rubber  ligature  should  be  used. 
The  tumor  should  now  be  cut  away.  If  the  pedicle 
is  long  and  not  involved  by  the  tumor  it  should  be 
severed  close  to  the  tumor,  thus  leaving  abund- 
ance of  tissue  external  to  the  clamp.  If  the  pedicle 
is  short  and  encroached  ui)on  by  the  tumor,  the  inci- 
sion should  extend  around  the  base  of  the  tumor  at  a 
distance  of  at  least  two  inches  from  the  provisional 
rubber  ligature,  involving  the  peritoneal  coat  and  con- 
nective tissue  capsule  of  the  tumor  (the  pedicle  edges 
of  the  incision  being  caught  on  three  sides  by  hemo- 
static forceps  to  control  the  stump  and  prevent  sliiJ- 
ping  of  the  ligature),  and  the  tumor  is  enucleated, 
leaving  a  pedicle  of  connective  tissue,  blood  vessels 
and  peritoneum. 

The  pedicle  is  treated  in  both  cases  alike.  If  blood 
vessels  of  considerable  size  are  found  in  the  free  end 
they  should  be  ligated  separately  close  down  to  the 
provisional  clamj)  or  ligfiture.  Then  a  strong  anti- 
septic catgut  or  silk  ligature  should  transfix  the  pedi- 


167 


cle  near  its  edges,  and,  after  tying  the  first  knot  the 
provisional  clamp  or  ligature  should  be  removed  and 
the  ligature  securely  tied,  so  as  to  secure  every  portion 
of  the  pedicle.  If  care  has  been  observed  to  eliminate 
all  uterine  or  tumor  tissue  from  the  pedicle  it  will  be  as 
secure  now  as  an  ordinary  pedicle  of  an  ovarian  cyst. 
The  pedicle  should  be  trimmed  down  to  within  an  inch 
of  the  final  ligature. 

The  writer  has  removed  two  pedunculated  fibroids  of 
large  size  in  this  manner,  one  of  ten  pounds  and  another 
of  eight  pounds,  in  which  pregnancy  existed,  the  women 
both  going  on  to  term  afterward  and  giving  birth  to 
their  children  without  complications.  One  of  these 
conceived  afterward.  Another  case  of  this  kind  in  which 
a  tumor  of  large  size  was  removed,  afterward  conceived 
and  gave  birth  without  complications  to  a  living  child. 

2.  Tumor  developed  into  the  broad  Ligaments. — It 
is  not  a  rare  complication  to  find  these  tumors  of  the 
uterus  develoxDed  in  the  folds  of  the  broad  ligament 
to  such  an  extent  that  the  ligament  is  si^read  out 
over  the  growth  and  its  folds  tense.  Frequently  it 
will  be  impossible  to  deliver  the  uterus  until  the  por- 
tion has  been  enucleated  from  the  broad  ligament. 
The  line  of  procedure  here  is:  First,  enucleate  the 
tumor  from  the  broad  ligament,  and  second,  deliver 
the  uterus  as  in  uncomplicated  cases  and  complete  the 
toilet  in  the  same  manner. 

First  step:  Tie  if  possible  the  ovarian  artery  near 
the  outer  edge  of  the  tumor  near  the  pelvic  walls.  If 
more  convenient  a  provisional  forcep  may  be  used  to 
secure  the  vessel. 

Second  step:  Split  the  tense  peritoneum  which 
represents  the  broad  ligament,  the  folds  of  which 
have  been  eradicated  by  the  burying  tumor,  by  draw- 
ing a  scalpel  over  it  at  its  most  prominent  i3oint  in  a 
direction  from  the  uterus  to  the  side  of  the  pelvis. 
Then  with  the  fingers  or  some  blunt  instrument  the 
tumor  is  gradually  peeled  from  its  subperitoneal  bed, 
constant  traction  being  exerted  on  it  until  the  uterus 
and  tumor  are  delivered. 


168 


Third  step;  Completion  of  the  operation  as  in  a 
normal  case. 

3.  Interstitial  Tumors  involving  the  Cervix. — When 
the  fibroid  has  developed  low  in  the  substance  of  the 
uteiiis  so  as  to  occuj)y  the  cervix,  some  management 
is  required  in  order  to  secure  a  proper  pedicle.  Two 
methods  may  be  pursued;  first,  complete  enucleation 
of  the  fibroid  tissue  from  the  cervix,  and  second,  com- 
plete removal  of  the  cervix. 

When  it  is  possible,  I  prefer  to  enucleate  the 
tumor  from  the  cervix  in  order  to  preserve  that  por- 
tion of  the  uterus  for  a  pedicle  and  a  key  to  the 
abdominal  floor. 

The  first  part  of  the  operation  is  conducted  as  in  a 
normal  case  or  if  any  portion  of  the  tumor  is  subperi- 
toneal as  in  the  last  method  described.  When  the 
region  of  the  large  cervix  is  reached,  a  blunt  instru- 
ment should  be  employed  to  comj^letely  enucleate  it 
from  all  surrounding  tissue,  the  bladder  in  front  and 
all  lateral  tissue  in  order  to  insure  perfect  security  of 
the  ureters.  This  can  only  be  done  by  keeping  the 
point  of  the  enucleating  instrument  well  against  the 
uterine  tissue.  If  there  is  difficulty  in  securing  the 
uterine  arteries  definitely,  because  of  the  necessary 
distortion  of  the  tissues,  two  strong  Tait  pedicle-pins 
should  transfix  the  cervix,  at  right  angles  to  each 
other,  their  ends  being  supported  by  the  abdominal 
walls,  and  beneath  these  a  provisional  rubber  ligature 
should  be  placed.  The  tumor  is  then  cut  away,  down 
to  the  i^edicle-pins,  and  the  uterine  arteries  are  sought 
and  tied.  After  insuring  hemostasis,  the  elastic  lig- 
ature is  removed  and  the  fibroid  tissue  of  the  cervix 
carefully  j^eeled  out  of  its  ca})sule.  From  this  point 
the  case  is  treated  as  a  normal  hysterectomy. 

Removal  of  the  cervix:  Occasionally  it  may  seem 
l)est  to  remove  the  entire  cervix  when  it  is  the  seat  of 
the  fibroid  invasion.  The  same  course  should  be 
pursued  here  as  when  the  cervix  is  to  be  retained. 
The  uterus  may  or  may  not  be  severed  above  a  provi- 
sional  elastic   ligature,    before   ligating   the   uterine 


169 

arteries.  When  the  cervix  has  been  thoroughly 
stripped  and  the  vagina  rendered  aseptic,  the  vagina 
should  be  opened  at  the  anterior  or  i^osterior  cul-de- 
sac  close  to  the  cervix,  and  one  blade  of  a  curved  pair 
of  scissors  slipped  through  into  the  vagina,  and  the 
cervix  completely  severed  from  its  vaginal  attachment 
by  following  the  circumference  of  the  cervix  with  the 
scissors.  A  guide  in  the  vagina  in  the  form  of  a  staff 
may  be  employed  in  making  the  first  vaginal  incision. 
If  there  are  any  small  bleeding  points  on  the  vaginal 
edges  they  should  be  tied  with  catgut  or  twisted  with 
hemostatic  forceps.  The  vagina  should  be  loosely 
packed  with  sterilized  iodoform  gauze  from  above  so 
as  to  just  reach  to  the  upper  end  of  the  severed  vagina. 
The  tissues  in  the  bottom  of  the  pelvis  naturally  fall 
together.  ^With  abundant  drain  in  the  vagina  I 
simply  allow  the  upper  end  of  the  vagina  and  the 
other  severed  tissues  to  fall  together  naturally,  con- 
tenting myself  to  close  the  peritoneum  alone  with  a 
running  antiseptic  catgut  suture,  exactly  as  when  the 
cervix  is  allowed  to  remain. 

4.  Tumors compliccdedwiih diseased Aiypendacjcs. — 
Diseased  aiDpendages  are  a  frequent  accomj)animent  of 
fibroids  of  the  uterus.  When  fibroids  demanding  a 
hysterectomy  are  complicated  with  diseased  append- 
ages the  disease  of  the  adnexia  should  be  treated  in 
the  ordinary  way,  and  then  the  hysterectomy  should 
be  carried  out  on  the  lines  best  suited  to  the  case. 

Cysts  of  the  ovary,  without  adhesions,  scarcely  com- 
plicates a  hysterectomy  for  fibroids.  The  pedicle  of 
the  tumor  is  at  once  ligated  with  strong  silk  or  clamj^ed 
with  strong  forceps  and  the  tumor  removed.  If  it  is 
of  considerable  size  it  may  first  be  emptied  with  a 
trochar. 

Pyosalpinx  should  be  attacked  as  though  no  fibroid 
existed.  If  there  has  been  bilateral  disease  of  the 
appendages  with  extensive  peritonitis  and  numerous 
adhesions,  the  adhesions  should  be  carefully  separated 
and  the  diseased  pus  tubes  and  ovaries  oarefully  enu- 
cleated and  removed.     Then  the  uterus  is  removed  in 


170 


the  ordinary  way.  The  matter  of  drainage  should  be 
dealt  with  here  exactly  as  when  no  hysterectomy  fol- 
lows, except  that  it  may  oftener  be  more  convenient 
to  drain  through  the  vagina.  If  enucleation  of  the 
appendages  has  been  such  that  large  peritoneal  adhe- 
sions have  been  separated  and  there  is  considerable 
unavoidable  oozing  from  raw  surfaces,  some  form  of 
drain  is  imperative.  As  the  most  dejpendent  portion 
of  the  ijelvis  is  Douglas's  cul-de-sac,  one  should  select 
that  point  from  which  to  make  vaginal  drain.  Fig.  30 
crudely  represents  an  instrument  I  have  devised  for 
opening  the  cul-de-sac  and  guiding  my  drainage  gauze 
into  the  vagina.  The  lower  instrument  represents 
a  staff  which  is  placed  in  the  vagina  as  a  guide,  with  a 


Figure  30. 

tubular  end  which  will  act  as  a  counter  pressure  for  the 
pointed  dressing  guide  which  penetrates  the  cul-de- 
sac  from  the  pelvic  cavity.  The  upper  instrument  is 
a  hollow  forcei^s  with  pointed  blades,  which  when 
they  have  penetrated  into  the  vagina  guided  by  the 
staff  are  opened  and  a  strip  of  gauze  of  any  size  may  be 
pushed  ]')etween  them  and  drawn  through  from  below. 
The  tubular  forceps  may  also  act  as  a  guide  for  a 
rubber  drainage  tube.  Those  who  have  attempted  to 
place  drainage  tubes  or  gauze  without  a  i^roper  guide 
will  ajjpreciate  the  advantage  of  this  instrument. 

So,  after  the  uterus  is  removed  a  roll  of  sterilized 
strip  gauze  about  the  size  of  the  index  finger  should 


171 


be  drawn  through  the  cul-de-sac  into  the  vagina,  the 
vagina  loosely  packed  with  gauze  below  and  a  packing 
left  in  the  lower  part  of  the  pelvis  sufficient  to  take 
care  of  any  oozing  from  the  peritoneal  surfaces,  Fig.  31. 
The  toilet  of  the  peritoneum  is  completed  as  in  ordi- 
nary cases  and  the  abdominal  wound  closed.  The 
dressing  used  as  a  drain  is  removed  as  soon  as  it  no 
longer  soils  the  dry  dressings  which  are  placed  in  con- 
tact with  it  at  the  vaginal  outlet,  usually  from  twenty- 
four  to  forty-eight  hours. 


Figure  31. 

5.  Suppurating  Fibroids — Infected  fibroids  in 
which  there  is  extensive  interstitial  suppuration  are 
extremely  rare.  I  have  not  seen  more  than  two  such 
cases  in  my  experience.  One  of  these  I  removed. 
The  tumor  had  been  infected  more  than  a  year  before 
I  operated  on  it.  Several  abscesses  formed  at  inter- 
vals in4he  interior  of  the  walls  of  the  large  uterus 
and  then  discharged  through  the   cervix.     The  case 


172 

failed  to  successfully  drain  after  several  operative  pro- 
cedures which  I  attempted  through  the  cervix. 
Finally  I  decided  to  do  a  complete  abdominal  hyste- 
rectomy, one  which  would  also  include  the  infected 
cer^'ix.  The  operation  is  performed  practically  as 
described  above  for  the  complete  removal  of  the  ute- 
rus including  the  cervix.  Extreme  care  must  be  main- 
tained to  proteCc  the  abdominal  contents  and  perito- 
neum from  the  infected  contents  of  the  uterus.  If  the 
vaginal  track  is  employed  for  drainage,it  should  be  thor- 
oughly cleansed  first  by  a  competent  assistant  who  is 
not  allowed  to  further  participate  in  the  operation.  All 
drain  gauze  should  be  drawn  from  above  downward, 
never  the  reverse. 

6.  Tumors  coinpliccded  icith  Pregnancy. — Fibroid 
tumors  of  large  size  complicated  with  pregnancy  de- 
mands the  sacrificing  of  the  product  of  conception 
and  the  removal  of  the  uterus. 

Symptoms:  The  symptoms  of  pregnancy  are 
usually  all  present  in  an  exaggerated  form.  Men- 
struation which  has  heretofore  been  excessive  and 
frequent  on  account  of  the  fibroid  will  cease  abruptly. 
The  tumor  will  begin  to  grow  rapidly.  Pressure 
symptoms  are  much  exaggerated.  The  bowels  and 
bladder  will  become  crowded  and  sacralgia  and  dys- 
uria  will  result.  In  a  word,  all  the  ordinary  symp- 
toms of  growing  fibroids  of  the  uterus  minus  hem- 
orrhage, and  all  the  classical  symptoms  of  pregnancy, 
will  become  magnified  to  a  painful  degree. 

Pedunculated  fibroids  of  the  subperitoneal  variety, 
with  small  thin  pedicles  complicating  pregnancy  may 
be  removed  in  the  manner  described  in  this  lecture 
under  the  head  of  pedunculated  fibroids,  without  dis- 
tur})ing  the  contents  of  the  uterus.  If  the  tumor 
involves  the  uterine  walls  to  any  marked  degree  and 
the  tumor  is  so  large  that  it  will  prevent  full  develop- 
ment of  the  fetus  or  its  development  to  the  point  of 
viability,  or  the  tumor's  jjosition  is  such  that  it  will 
interfere  with  the  jjregnancy  taking  its  proper  course, 
the  entire  uterus  should  be  removed  with  the  tumor. 


173 

if  it  is  considered  necessary  to  remove  the  tumor  at 
once.  If  pregnancy  is  known  to  exist  before  an  o^^era- 
tion  is  determined  on  for  the  removal  of  the  tumor,  as 
a  rule  it  would  be  safer  to  empty  the  uterus  as  an 
early  preliminary  measure,  if  it  is  feasible,  reserving 
the  operation  on  the  tumor  for  a  time  after  convales- 
cence from  the  abortion  is  accomplished. 

Operation:  However,  if  it  actually  becomes  neces- 
sary to  remove  a  fibroid  uterus  complicated  with  preg- 
nancy, either  as  a  matter  of  choice,  or  accident  from 
mistaken  diagnoses,  the  operation  is  proceeded  wdth 
exactly  along  the  lines  of  an  ordinary  abdominal  hys- 
terectomy. As  a  rule  under  these  circumstances,  the 
broad  ligaments  are  loose,  and  the  uterus  freely  mov- 
able making  a  hysterectomy  comiDaratively  easy.  Any 
complication  should  be  dealt  with  as  in  ordinary 
cases. 

7.  Extra-peritoneal  Fibroids. — It  is  not  infre- 
quent that  one  w^ill  find  in  multiple  fibroids  that  one 
or  several  of  the  centers  of  growth  have  developed 
low  in  the  pelvis  and  in  their  increase  in  size  they 
have  gradually  elevated  the  peritoneum  and  grown 
beneath  it  until  they  have  become  actual  extra-perito- 
neal growths.  The  degree  of  such  complication  vary 
much  in  different  cases,  from  a  small  nodule  growing 
beneath  the  peritoneum  from  the  cervix  to  a  tumor 
weighing  several  pounds  elevating  the  peritoneum  in 
an  irregular  manner  and  distorting  all  the  organs  of 
the  pelvis. 

Method  of  Procedure:  These  cases  are  all  subject 
to  removal  if  they  are  handled  in  the  projper  manner. 
They  must  be  enucleated.  The  peritoneum  covering 
the  abdominal  surface  of  the  tumor  must  be  carefully 
severed  at  its  point  of  deflection  from  the  tumor  on 
to  the  parietes.  The  tumor  should  then  be  grasped 
with  strong  blunt  toothed  vulsellum  forceps  and  while 
traction  is  being  made  to  deliver  the  tumor  the  fin- 
gers should  carefully  enucleate  the  growth  from  its 
bed.  Great  care  should  be  observed  in  order  to  enu- 
cleate it  perfectly  and  free  it  absolutely  from  the  ure- 


174 


ters  or  the  rectum  walls.  By  following  the  enuclea- 
tion the  tumor  will  finally  lead  to  its  pedicle  which 
will  be  the  uterus.  The  cavity  from  which  it  is  enu- 
cleated should  be  packed  temporarily  wdth  sterilized 
gauze  sponges  in  order  to  check  serious  oozing. 
When  the  tumor  is  finally  enucleated  and  removed, 
together  with  the  uterus,  in  the  ordinary  manner,  the 
work  of  making  a  pelvic  floor  must  be  accomplished. 
If  there  is  not  peritoneum  enough  left  to  cover  the 
floor  of  the  iDelvis  and  a  large  raw  surface  is  inevit- 
able, this  should  be  drained  into  the  vagina  by  a  roll 
of  gauze  an  inch  in  diameter  with  a  packing  in  the 
pelvis  sufficiently  large  to  cover  the  denuded  surface. 
Occasionally  the  cavity  from  which  the  tumor  is  enu- 
cleated may  be  packed  with  gauze  and  drained  into 
the  vagina  as  a  subperitoneal  pocket  and  the  perito- 
neum closed  over  it.  As  a  rule  these  cases  require 
drainage. 


IN  DEX. 


A 
Abdovien: 

Contour,  with  fibroids 19 

Abdominal  auscultation  ....    22 

Abdominal  electrodes 50 

Abdominal  Hysterectomy 153 

Complete  removal 157 

Complicated  cases 165 

Drainage 170 

Extra-peritoneal  method.  .   .156 

History 155 

Indications 160 

Intra-peritoneal  method.  .   .  .156 
Stimpson-Baer  method.  .   .   .  IGO 

Technique 161 

Vaginal  fixation 158 

Abdominal  incision S3 

Abdominal  palpation 22 

Abdominal  Avound-closing.  .   .  132 

Adhesions 126 

Adhesions  following  laparoto- 
my  85 

After-treatment: 

"Bowels 89 

Care  of  glass  drain 8» 

Care  of  gauze  drain 88 

Diet 90 

Dressings 88 

Forceps 150 

Laparotomy .87 

Vaginal  Hysterectomy.  .   .   .  150 
After-treatment  of  laparotomy.  87 

Albert,  Dr 157 

Abdominal  Hysterectomy  .  .  157 

Aloin 28 

Alteratives 29 

Ammonium  muriate 29 

Analysis  of  cases.  .* 138 

Anteversion 23 

Antifebrin 31 

Antipyriu 81 

Ajjpeiidaties: 

Diseased 126 

Removal  of 117 

Arrangement  of  operating  room.  79 

Arsenic 29 

Artificial  menopause 117 

Asafedita 33 

Ashton,  Dr b5 

Astringents 33 

Astruc: 
Nerves  in  myomata 8 

B 

Ballottement 25 

Baths  for  fibroids 28 

Battery: 
Office 47 


Portable 46 

Primary 46 

Battey  operation 117 

Belladonna 32 

Bidder: 
Nerves  in  myomata 8 

Bimanual  examination 21 

Bladder: 

Effects  of  fibroids 18 

In  vaginal  hysterectomy.    .   .  149 

Blood  supply  of  uterus 118 

Blood  vessels: 

In  fibroids 8 

Effect  of  galvinism 53 

Blue  mass 30 

Blundell: 
Vaginal  hysterectomy  ....  136 

Boeckmann  sterilizer 71 

Booth,  Dr 74 

Bowels: 

After-treatment 89 

Preparation gi 

Bromids 31 

Burnham,  Dr 15.5 

Byford,  W.  H. 
Administration  of  blue  mass.  30 

Byford,  H.T 158 

Clamp  forceps 142 

Ergot  for  fibroids 40 

Vaginal  fixation  of  stump  .   .  158 

C 

Calumbo 28 

Cancer  of  uterus .  24 

Cannabis  indiea 32 

Capillary  drain iso 

Cascara  sagrada :.8 

Cataphoric  action  of  galvanic 

current 55 

Catgut 70 

Cells:                                         ■    ■    .    .  - 

Diamond  carbon 47 

Law 47 

Le  Clanche 47 

(■ern'x: 

In  pregnancy 25 

Position  Avith  fibroids 20 

Chloral 31 

Chlorid  of  iron 34 

Chlorid  of  zinc 34 

Cinchona 28 

Clamp  forceps 142 

Clay  electrodes .51 

Closing  abdominal  wound.  .  .  132 
Complications  in  livstorectomy.165 
Cohnheim's etiology  of  fibroids.  14 

Constipation 19 

Constitutional  disturbances  .   .    19 


I 


INDEX. 


Copper  electrodes 52 

Curettement 116 

Current,  street  wire 47 

Czernv '. 
Vaginal  hysterectomy 136 

D 
Deformity  produced  by  fibroids.  19 
Delbaeh: 
Vaginal  hysterectomy  ....  13b 

Diagnosis  of  fibroids 17 

Diet 90 

Differential  diagnosis  of  fibroids  23 

Diseased  appendages 126 

Diseased  appendages  in  abdom- 
inal hysterectomy 169 

Dorsett,  Dr 93 

Douches: 
After  vaginal  hysterectomy  .  151 

Preparatory 83 

Drainage ^°* 

In  fibroids 1<0 

In  oophorectomy 127 

Dress 1° 

Dressings.     •  •       • .°° 

Dressing  the  wound irfo 

Dudley:  ^  _. 

Vaginal  hysterectomy  ....  lab 
Dupuytren : 

Nerves  in  myomata v 

Dysmenorrhea,  with  fibroids.  .    18 

E 
Eastman : 

Abdominal  hysterectomy.  .   . 
Elect  r  if  ity: 

Apparatus 

Current 

Indications  for  use 

Electrodfft 

Abdominal 

Clay 

Copper 

Flexible 

Intrauterine 

Rectal 

Vaginal 

Emmet: 

Etiology  of  fibroids 

Ergot: 

Duration  of  treatment .   ... 

I'lTect  on  interstitial  fibroids 

Effect  on  intramural  fibroids 

Effect  on  submucous  fibroids 

Eff(-ct  on  peritoneal  fibroids 

Indications .•   •   •   • 

M<'thod  of  administration  .   . 

Physiologic  action 

Results 

Es.selman : 

Vaginal  hysterectomy  .... 

'vaginal  hysterectomy  .... 
Extra-peritoneal  fibroid  .... 

F 

Ferguson  stitch 

Fibrocysts 


157 

46 
46 
57 
50 
50 
51 
52 
51 
51 
52 
52 

14 

43 

.  38 

.  38 

.  38 

.  88 

39 

41 

37 

4^1 

136 

i:^(; 
n:; 

9 


Fibroids: 

Anatomy 5 

Carcinomatous  degeneration,  11 

Classification 5 

Degenerative  changes 9 

Diagnosis 17 

Electricity  in 46 

Etiology 13 

Histologic  changes 7 

Medical  treatment 27 

Minor  surge rj- 114 

Spontaneous  disappearance  .    11 
Spontaneous  expulsion.  ...    12 

Suppurating 171 

Symptoms 17 

Treatment 26 

Floating  kidney 20 

Fetal  movements 25 

Fetal  heart  tones 25 

Forceps 150 

Functional  disturbances  ....  18 

G 

Galvanisin: 
Applied     to      treatment     of 

fibroids 56 

Chemic  reaction 53 

Effect  on  blood  vessels.   ...    53 
Etfect  on  living  tissues.   ...    53 

Effect  on  microbes M 

Effect  on  sensibility 53 

General  effect 56 

Interpolar  effect 54 

Polar  effect 53 

Garrigues : 

Histology  of  myomata 7 

Gauze 76 

General  astringents 35 

General  tonics 27 

Getting  up 152 

Glass  drain 128 

Glass  syringe 129 

Goffe: 
Abdominal  hysterectomy  .  .  157 

Goodell's  dilators 116 

Gottschalk,  Prof 93 

Gusserow : 
Disappearance  of  fibroids  .  .    12 

H 

Hartz: 

Nerves  in  myomata 8 

Hegar : 

Abdominal  liysterectomy.  .   .  155 
Hegar's  operation,  .   .       ....  117 

Hildebrandt : 

Ergot  in  treatment  of  fibroids,  40 
Hofmcier : 

Alxlominal  hysterectomy.  .   .  157 

Hydrastis  Canadensis 85 

Hyoscyamus 28 

Hy])OSulpliites 28 

JIi/HtcrrctD'iin/: 

Abdominal.  ..." 155 

Vaginal 135 


Inoperable  cases 61 


INDEX. 


Instrument: 

Used  in  vaginal  drainage.  .  .  170 
Instrumental  examination.  .   .    21 

Internal  electrodes 51 

Interpolar  electrolysis 56 

Interstitial  tumors  of  cervix  .   .  168 

Intestinal  obstruction 85 

Intrauterine  electrode 51 

lodin 29 

Iron 34 

J 
Jones,  Dr.  Mary  A. 
Abdominal  hysterectomy.  .   .  157 

K 
Kelly: 

Abdominal  hysterectomy.  .   .156 

Kidneys SO 

Kimball,  Gillman: 

Abdominal  hvsterectomv.  .  .  155 
Klebs : 

Etiology  of  fibroids 13 

Kleeberg : 

Abdominal  hysterectomy.  .  .  155 
Kleinwachter : 

Etiology  of  fibroids 13 

Koeberle : 

Abdominal  hysterectomy.  .   .  155 

Fibrocysts 10 

L 

Lane: 
Vaginal  hysterectomy   ....  136 

Langenbeck : 
Vaginal  hysterectomy  ....  130 

Laparotomii: 

After-treatment 87 

For  removal  of  ovaries  .  .  .  .120 
For  removal  of  uterus  ....  155 
Preparation  of  bowels  ....  81 
Preparation  of  patient  ....    S3 

Latta: 
Abdominal  hysterectomy.  .   .  155 
Vaginal  hysterectomy  ....  136 

Leopold : 
Theory  of  fibrocysts 10 

Ligation  of  uterine  arterie><: 

After-treatment 98 

Report  of  cases 100 

Selection  of  cases 98 

Technique 94 

Ligatures 68 

Ligatures  in  vaginal  hysterec- 
tomy       149 

Lithotomy  pcntion  : 
For  ligation  of  arteries  .   ...    94 
For  vaginal  hysterectomy  .   .  139 

Lymphatics  in  fibroids 9 

M 

Marcy : 

Abdominal  hysterectomj'.  .   .  157 

Martin,  Dr .155 

Medical  treatment  of  fibroids  .  27 
Meinhert : 

Abdominal  hysterectomy .  .  .  158 
Membranous  electrodes.  .   .   .   .    51 


Menstruation  -with  fibroids.  .  .    18 

Mercury 29 

Mllliampere  meter 49 

Minor  surgery: 
Submucous  fibroids 114 

Mitchel : 
Etiology  of  fibroids 15 

Morcellement: 

Accidents 148 

Indications 144 

Remarks 148 

Technique 144 

Uterus  more  than  doul>le.  .   .  146 
Variations 146 

Myomata : 
Histology 7 

N 
Nelson : 
Report    of     treatment     with 

ergot 45 

Nephritis 81 

Nerves  in  fibroids 8 

Nitrate  of  silver 35 

Nux  vomica 28 

O 

Objective  symptoms 20 

Olshausen : 
Abdominal  hj'Sterectomj-.  .   ,  157 

Ooptiorcctomij : 

Adhesion.s 126 

After-treatment 133 

Drainage 127 

Dressings 133 

Exploration 122 

Indications 120 

Operation 121 

Vaginal  drainage 130 

Operating  room 66 

Opium SS 

Orarian  cyxt: 
Diagnosis 25 

P 

Parkes : 
Abdominal  hysterectomy.  .   .  157 

P(^an: 
Abdominal  hysterectomy.  .   .  155 

Pedicle: 
Of  submucous  fibroid 115 

Pedunculated  tumors 165 

Pelvic  examination 20 

Phenacetin 61 

Polk : 
Abdominal  hysterectomy.  .   .  158 

Pozzi : 

Etiology  of  fibroids 13 

Fibrocysts 9 

Histology  of  myomata  ....     8 

I'regiiaiicy: 

Complicating  fibroids 172 

Normal 24 

Tubal 25 

Prepared  foods 28 

Prcixirittion  i>j: 

Catgut.  .   ." 72 

Hands 78 


IV 


INDEX. 


Patient 80 

Vagina 83 

Price,  Joseph l"i^> 

Pyoktanin 73 

Pyosalpinx 120 

Q 

Quassia 28 

Quinin 28 

R 

Recamier: 

Vaginal  hysterectomj- ....  136 

Rectal  electrodes -32 

Rectum  with  fihroids 1« 

Removal  of  appendages 117 

Removal  of  cervix 168 

Results    of    vaginal    hysterec-  _ 

tomy 1-53 

Retroversion 23 

Rheostat— xMcIntosh 48 

Robinson,  Dr.  Byron 119 

Roux: 

Vaginal  hysterectomy  ....  136 

S 
Sauter  i 

Vaginal  hysterectomy  ....  136 
Schroeder's  abdominal  hyster- 
ectomy  1-56 

Sedatives 31 

Seibold : 

Vaginal  hysterectomy  ....  136 
Senn: 
Abdominal  hysterectomy.  .   .  160 

Etiology  of  fibroids 14 

Sensibility: 

Effect  of  galvanism 53 

Silk Jl 

Silkworm  gut /I 

Sims'  position 34 

Speculum 22 

Sponges 74 

Stenli/ers o» 

Stimson-Raer: 
Abdominal  hysterectomy.  .   .  156 

Storage  batteries 48 

Stramonium 32 

Strychnia 28 

Subinvolution 23 

Submucous  fibroids 114 

Stump  in  abdominal    hysterec- 
tomy  103 

Superficial  stitches 133 

Suppurating  fibroids 171 

Sutttm,  Bland: 
Blood  vessels  in  fibroids  ...     8 

Fibrocysts 9 

Histology  of  fibroids 7 

Sutures 68 

Syringe 129 

T 

Tait  operation 117 

Terfmiiiiif;: 
Abdominal   hysterectomy  .   .  161 
Application  of  electricity.  .   .    58 


Ligation  of  uterine  arteries. .   94 

Oophorectomy 121 

Vaginal  hysterectomy  ....  138 

Treatment  of  fibroids: 
Abdominal  hysterectomy.  .   .  155 

Electrical 58 

Ligation  of  uterine  arteries  .   92 

Medical 26 

Minor  surgical 114 

Morcellcment 144 

Vaginal  hysterectomy  ....  135 

Trendelenburg  position  ....  165 

Tubal  pregnancy 25 

Tumors: 

In  l)road  ligament 167 

Complicating  pregnancy.   .   .  172 

U 

Urination 19 

Uterine  artery— ligation  ....  92 

Uterine  contractions 18 

Uterine  disinfection 139 

Uterine  sound 22 

Uterus: 

Position  with  fibroids 20 

V 

Vagina  in  pregnancy 25 

Vaginal  douche 83 

Vaginal  electrodes 52 

Vaginal  fixation 158 

VcujindL  hi/stcrectomi/ : 

Accidents 148 

After-treatment 150 

Bj' morceilement 142 

Douches 151 

Drainage 143 

Dressings 151 

Forceps 142 

Getting  up 152 

History 135 

Indications 138 

Ligatures  149 

Operation 139 

Results 153 

Technique 138 

Vaginal  ligation 92 

Van  de  Walker: 

Abdominal  hysterectomy.  .      156 
Velpeau : 

Etiology  of  fibroids 13 

Virchow : 
Classification  of  inyomata.    .      H 
Fil)rocysts 9 

W 

Wells: 
Etiology  of  fibroids 15 

Winkle: 
Bhiod  vessels  in  myomata  .   .      8 

Etiology  of  fibi'oids 13 

Nerves  in  inyoinata 8 

Z 
Zweifel : 
Abdominal  hysterectomy.  .   .  L)7 


J.  J. 


COLUMBIA   UiNivr^ivoi 

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